Medical Director

Centene Corporation

1d•Hybrid

About The Position

Centene is a diversified, national organization offering competitive benefits and a fresh perspective on workplace flexibility. This full-time Medical Director position is within the Medical Management/Health Services team, where you will contribute to changing outcomes for 28 million members. Centene Corporation is a leading provider of government-sponsored healthcare coverage, including Medicaid, Medicare, and Health Insurance Marketplace services. This role offers a compelling opportunity to move beyond patient encounters and drive meaningful change in the community by directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. The position involves providing medical leadership for utilization management, cost containment, and medical quality improvement activities, ensuring timely and quality decision-making.

Requirements

MD or DO without restrictions
Must be licensed in Louisiana
Board Certified Physician
Medical Doctor or Doctor of Osteopathy
Actively practices medicine or has been an actively practicing physician within the last 5 years.
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.
Current Louisiana state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Nice To Haves

Utilization Management experience and knowledge of quality accreditation standards preferred.
Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
Experience treating or managing care for a culturally diverse population preferred.

Responsibilities

Assist the Chief Medical Officer to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
Supports effective implementation of performance improvement initiatives for capitated providers.
Assists Chief Medical Officer in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assists the Chief Medical Officer in the functioning of the physician committees including 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.
Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participates in provider network development and new market expansion as appropriate.
Assists in the development and implementation of physician education with respect to clinical issues and policies.
Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
Develops alliances with the provider community through the development and implementation of the medical management programs.
As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
Represents the business unit at appropriate state committees and other ad hoc committees.
May be required to work weekends and holidays in support of business operations, as needed.