Remote Behavioral Medical Director, Eastern 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 for utilization management, cost containment, and medical quality improvement activities. Perform medical reviews of complex, controversial, or experimental medical services to ensure timely and quality decisions.

Responsibilities

• Support the implementation of performance improvement initiatives for capitated providers.
• Assist the Chief Medical Director in planning and establishing goals and policies to enhance quality and cost-effectiveness of care and services for members.
• Provide medical expertise in operating approved quality improvement and utilization management programs according to regulatory, state, corporate, and accreditation requirements.
• Participate 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 with clinical teams, network providers, appeals team, medical and pharmacy consultants to review complex cases and medical necessity appeals.
• Engage in provider network development and new market expansion as necessary.
• Develop and implement physician education programs regarding 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 to improve quality and cost of care.
• Interface with physicians and other providers to facilitate implementation of recommendations for improving 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.
• Represent the business unit before various publics, both locally and nationally, on medical philosophy, policies, and related issues.
• Attend appropriate state committees and other ad hoc committees as needed.
• Work weekends and holidays as required to support business operations.

Requirements

• Medical Doctor or Doctor of Osteopathy.
• Utilization Management experience and knowledge of quality accreditation standards preferred.
• Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management advantageous.
• Experience treating or managing care for a culturally diverse population preferred.
• Board certification by the American Board of Psychiatry and Neurology, with Child Psychiatry certification preferred.
• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Qualifications

• Experience practicing medicine.
• Knowledge of healthcare regulations and accreditation standards.
• Strong communication and collaboration skills.
• Ability to manage complex medical cases and make informed decisions.
• Proficiency in medical terminology and healthcare policies.

Skills

• Medical knowledge and expertise.
• Leadership and strategic planning skills.
• Collaborative problem-solving abilities.
• Effective communication and interpersonal skills.
• Ability to work independently and as part of a team.

Benefits

Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. 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.

Pay

$236,500.00 - $449,300.00 per year

Schedule

Fully remote, hybrid, field, or office work schedules may be offered based on business needs.