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 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 the effective 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 in accordance 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.

Qualifications

• 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.

Pay

$236,500.00 - $449,300.00 per year

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.

Equal Opportunity Employer

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.