Medical Director

We’re Hiring: Full time Medical Director

Centene Corporation is a leading provider of government-sponsored healthcare coverage, providing access to affordable, high-quality services to Medicaid and Medicare members, as well as to individuals and families served by the Health Insurance Marketplace.

Looking for a compelling opportunity to move beyond patient encounters and drive meaningful change in the community?

Qualifications for this role include:

• MD or DO without restrictions
• Must be licensed one of the following states: MO, IL, KS, IA, NE, MI, WI, IN, OH, PA
  

Position Purpose:
Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.

• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.

• Supports effective implementation of performance improvement initiatives for capitated providers.

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

• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.

• Assists 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.

• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.

• Participates in provider network development and new market expansion as appropriate.

• Assists in the development and implementation of physician education with respect to clinical issues and policies.

• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.

• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.

• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.

• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.

• Develops alliances with the provider community through the development and implementation of the medical management programs.

• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.

• Represents 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.

Education/Experience:
Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medici]]><