Remote Medical Director, Appeals

Centene Corporation; Deutschland; Hybrid; EUR 203.000 - 387.000; Vollzeit

Benefits dieser Stelle

Health insurance

401K

Stock purchase plan

Tuition reimbursement

Paid time off

Flexible work arrangements

Remote/hybrid/field/office options

Zusammenfassung

Centene Corporation is seeking a clinical leader to assist the Chief Medical Director in directing medical management, quality improvement, and credentialing for the business unit. You will provide medical leadership for utilization management, cost containment, and quality improvement activities, while reviewing complex cases and ensuring timely, quality decisions.

You will support performance improvement initiatives across capitated providers, collaborate with clinical teams and committees,

Qualifikationen

• MD/DO actively practicing medicine.
• Utilization Management experience and knowledge of accreditation standards preferred.
• Experience treating a culturally diverse population preferred.
• Course work in Health Administration, Financing, Insurance or Personnel Management is advantageous.

Aufgaben

• Provide medical leadership for utilization management, quality improvement, and credentialing activities.
• Perform medical review related to utilization review, quality assurance, and complex or experimental services.
• Support performance improvement initiatives for capitated providers.
• Assist the Chief Medical Director in planning goals and policies to improve quality and cost-effectiveness of care.
• Provide medical expertise in quality improvement and utilization management programs per regulatory and accreditation requirements.
• Assist in physician committee functioning, structure, processes and membership.
• Conduct rounds to assess high-risk patient care with care management teams.
• Collaborate with clinical teams, providers, appeals team, consultants for reviewing complex cases and medical necessity appeals.
• Participate in provider network development and new market expansion as appropriate.
• Assist in physician education related to clinical issues and policies.
• Identify utilization review studies and adverse trends; evaluate provider practice patterns.
• Identify clinical quality improvement studies to reduce unwarranted variation and improve quality and cost of care.
• Interface with physicians and other providers to implement recommendations.
• Review complex or new services for medical necessity and payment.
• Develop alliances with the provider community through medical management programs.
• Represent the unit before publics on medical philosophy and policies as needed.
• Represent the unit at state committees and ad hoc committees.
• May require weekends/holidays to support operations.

Ausbildung

Medical Doctor or Doctor of Osteopathy

Utilization Management experience and knowledge of quality accreditation standards

Actively practices medicine

Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management

Experience treating or managing care for a culturally diverse population

Jobbeschreibung

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

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 medicine.
• 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.

License/Certifications:

• 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 Range: $236,500.00 - $449,300.00 per year

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.

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