Remote Behavioral Medical Director, Central Region

Position Purpose

Aid the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. Provide medical leadership in utilization management, cost containment, and medical quality improvement activities. Perform medical review activities for utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.

Responsibilities

• Support effective implementation of performance improvement initiatives for capitated providers.
• Aid the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provide medical expertise in the operation of approved quality improvement and utilization management programs in compliance with regulatory, state, corporate, and accreditation requirements.
• Assist the Chief Medical Director 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.
• Collaborate effectively with clinical teams, network providers, appeals team, 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 with respect to clinical issues and policies.
• Identify utilization review studies and evaluate adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Interface with physicians and other providers to facilitate implementation of recommendations to providers 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 the medical management programs.
• 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.

Requirements

• Medical Doctor or Doctor of Osteopathy.
• 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.
• Board certification by the American Board of Psychiatry and Neurology.
• Preferred certification in Child Psychiatry.
• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Qualifications

• Active practice of medicine.

Skills

• Strong communication and collaboration skills.
• Knowledge of healthcare regulations and accreditation standards.
• Ability to manage and lead multidisciplinary teams.
• Proficiency in medical coding and billing systems.
• Excellent problem-solving and decision-making abilities.

Benefits

Centene offers a comprehensive benefits package including:

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules.

Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

Pay

$236,500.00 - $449,300.00 per year