Medical Director - UM Optimization

Centene Corporation • Remote-MO, MO

4d • $215,000 - $408,500 • Remote

About The Position

The Medical Director assists the Chief Medical Officer in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. This remote role provides medical leadership for Utilization Management (UM) and cost containment, with a focus on strategic planning and optimizing UM processes. The Medical Director evaluates completed work, analyzes data, and makes decisions about strategic process improvements, supporting the CMO and collaborating closely with nursing leaders.

The role provides medical expertise in operating utilization management and quality improvement programs in accordance with regulatory, state, corporate, and accreditation requirements. It includes reviewing complex or controversial cases, supporting provider performance improvement, contributing to physician committees and education, and working with clinical teams and providers to improve care quality and cost-effectiveness. The position may require weekend and holiday work as needed to support business operations.

Requirements

• Medical Doctor (MD) or Doctor of Osteopathy (DO).
• Current state medical license as an MD or DO without restrictions, limitations, or sanctions from government programs.
• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.
• Certification in Psychiatry is required.
• Actively practices medicine.

Nice To Haves

• Payer or managed care experience.
• Utilization Management experience and knowledge of quality accreditation standards.
• Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management.
• Experience treating or managing care for a culturally diverse population.

Responsibilities

• Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
• Perform medical review activities related to utilization review, quality assurance, and complex, controversial, or experimental medical services, ensuring timely and quality decision-making.
• Support effective implementation of performance improvement initiatives for capitated providers.
• Assist the Chief Medical Director in planning and establishing goals and policies to improve the quality and cost-effectiveness of care and services for members.
• Provide medical expertise in operating approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assist the Chief Medical Director with physician committee structure, processes, and membership.
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• Collaborate with clinical teams, network providers, the appeals team, and medical and pharmacy consultants to review complex cases and medical necessity appeals.
• Participate in provider network development and new market expansion as appropriate.
• Assist in developing and implementing physician education on clinical issues and policies.
• Identify utilization review studies and evaluate adverse utilization trends, unusual provider practice patterns, and the adequacy of benefit and payment components.
• Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice and improve the quality and cost of care.
• Work with physicians and other providers to implement recommendations that improve utilization and healthcare quality.
• Review claims involving complex, controversial, unusual, or new services to determine medical necessity and appropriate payment.
• Develop alliances with the provider community through development and implementation of medical management programs.
• As needed, represent the business unit locally and nationally on medical philosophy, policies, and related issues.
• Represent the business unit at appropriate state and other ad hoc committees.

Benefits

• Competitive pay
• Health insurance
• 401(k)
• Stock purchase plans
• Tuition reimbursement
• Paid time off and holidays
• Flexible approach to work schedules, including remote, hybrid, field, or office work
• Potential additional forms of incentives

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree