Remote Medical Director, Appeals

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.

Responsibilities

• Support the implementation of performance improvement initiatives for capitated providers.
• Assist 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.
• Collaborate with clinical teams, network providers, 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.
• Develop and implement physician education with respect to clinical issues and policies.
• Identify utilization review studies and evaluate adverse trends in utilization of medical services.
• Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice.
• Interface with physicians and other providers to facilitate implementation of recommendations.
• 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 and at appropriate state committees and other ad hoc committees.

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.
• Active 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.
• Certification in Internal or Family Medicine specialty, preferred.
• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Qualifications

• Experience in healthcare administration.
• Knowledge of healthcare regulations and accreditation standards.
• Strong communication and collaboration skills.
• Ability to manage multiple tasks and prioritize responsibilities.
• Proficiency in medical terminology and healthcare policies.

Skills

• Utilization Management
• Quality Improvement
• Medical Review
• Provider Network Development
• Physician Committee Participation
• Complex Case Review
• Medical Necessity Appeals
• Provider Education
• Quality Assurance

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.

Pay

$236,500.00 - $449,300.00 per year

Schedule

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