Remote Medical Director

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

• Perform medical review activities for utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
• Ensure timely and quality decision making in medical reviews.
• Support the implementation of performance improvement initiatives for capitated providers.
• Assist in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provide medical expertise in operating approved quality improvement and utilization management programs according to regulatory, state, corporate, and accreditation requirements.
• Assist the Chief Medical Director in physician committee functioning, 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.
• Develop alliances with the provider community through the development and implementation of medical management programs.
• Represent the business unit before various publics and state committees as needed.
• Review claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment.
• 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 to providers that would improve utilization and healthcare quality.
• Represent the business unit at 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 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, preferred.
• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Qualifications

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• A flexible approach to work with remote, hybrid, field or office work schedules.

Benefits

Centene offers a comprehensive benefits package including:

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• A flexible approach to work with remote, hybrid, field or office work schedules.

Pay

$236,500.00 - $449,300.00 per year

Schedule

Flexible work schedule