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. 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 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 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 certification in Child Psychiatry preferred.
• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Qualifications

• Experience practicing medicine.

Skills

• Strong medical knowledge and clinical expertise.
• Excellent communication and collaboration skills.
• Ability to manage complex medical cases and make informed decisions.
• Knowledge of quality accreditation standards and regulatory requirements.

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.

Company Information

Centene is an equal opportunity employer that is committed to diversity and values the ways in which we are different. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.