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 in utilization management, cost containment, and medical quality improvement activities.

Responsibilities

• Support the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• 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 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 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.

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

• Experience practicing medicine.
• Knowledge of healthcare regulations and accreditation standards.
• Ability to work independently and collaboratively with diverse teams.
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.

Skills

• Utilization Management
• Quality Improvement
• Medical Review
• Provider Network Development
• Physician Committee Participation
• Complex Case Review
• Medical Necessity Appeals
• Provider Education
• Quality Assurance
• Healthcare Quality Improvement Studies
• Provider Collaboration
• Claims Review
• Medical Management Programs

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.

Pay

$236,500.00 - $449,300.00 per year

Schedule

Flexible work schedule with options for remote, hybrid, field, or office work.