Medical Director

Centene Corporation•Remote-FL, FL

23d•$236,500 - $449,300•Hybrid

About The Position

Centene is seeking a full-time Medical Director for its Health Plan in Florida, focusing on Long Term Care (LTC) cases. This role offers a unique opportunity to move beyond direct patient care and drive significant change within the community. Centene Corporation is a prominent provider of government-sponsored healthcare, ensuring access to affordable, high-quality services for Medicaid and Medicare members, as well as individuals and families through the Health Insurance Marketplace. This position is part of the Medical Management/Health Services team and offers competitive benefits and workplace flexibility.

Requirements

MD or DO without restrictions
Board Certified Physician
Must be licensed in Florida
Florida Resident
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 Florida state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Nice To Haves

Internal Medicine or Family Medicine HIGHLY preferred
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 Director to direct and coordinate the medical management, quality improvement, and credentialing functions for the business unit.
Provide medical leadership for all utilization management, cost containment, and medical quality improvement activities.
Perform medical review activities related to utilization review, quality assurance, and medical review of 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 the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assist the Chief Medical Director in the functioning of 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.
Collaborate effectively with clinical teams, network providers, the appeals team, and medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participate in provider network development and new market expansion as appropriate.
Assist in the development and implementation of physician education regarding clinical issues and policies.
Identify utilization review studies and evaluate adverse trends in the utilization of medical services, unusual provider practice patterns, and the adequacy of benefit/payment components.
Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice to improve the quality and cost of care.
Interface with physicians and other providers to facilitate the implementation of recommendations that would improve utilization and healthcare quality.
Review claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment.
Develop alliances with the provider community through the development and implementation of medical management programs.
As needed, represent the business unit before various publics, both locally and nationally, on medical philosophy, policies, and related issues.
Represent 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.