Behavioral Health Medical Director - UM Optimization

Centene Management Company LLC; Missouri; Hybride; USD 215 000 - 409 000; Plein temps

Avantages offerts par ce poste

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible work schedules (remote,Hybrid

Résumé du poste

Centene Management Company LLC is seeking a remote BH Medical Director to lead medical management, quality improvement, and credentialing for Utilization Management. You will support the CMO, analyze data, and drive strategic process improvements in a payer/managed care environment.

Board-certified in Psychiatry with an active MD or DO license is required, and UM experience with accreditation knowledge is preferred. Some weekend coverage may be required to support operations.

Qualifications

• Board certification in Psychiatry with ABPN certification required.
• Current MD or DO license without restrictions.
• Utilization Management experience and knowledge of accreditation standards preferred.
• Experience in payer/managed care environment is heavily preferred.

Responsabilités

• Provide medical leadership for utilization management, cost containment, and quality improvement.
• Direct and coordinate UM, quality improvement, and credentialing activities for the unit.
• Evaluate completed work, analyze data, and drive strategic process improvements.
• Collaborate with clinical teams, network providers, and committees; participate in provider network development.
• Perform medical reviews and assess medical necessity and payment in complex cases; support performance improvement initiatives.

Connaissances

Payer/Managed Care experience

Data analysis

Strategic planning

Medical leadership

Formation

Medical Doctor or Doctor of Osteopathy

Course work in Health Administration / Health Financing

Description du poste

Position Purpose

Assist the Chief Medical Officer to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. This is a remote BH Medical Director role providing medical leadership for Utilization Management (UM) and cost containment. The focus of this role is on strategic planning and optimization of UM processes. The Medical Director will evaluate completed work, analyze data, and make decisions on strategic process improvements. This role will directly support the CMO while working closely nursing leaders. Ideal candidate will have in-depth knowledge in the UM space who is passionate about strategic planning and data analysis. Applicants must be board certified in Psychiatry, including board certification by the American Board of Psychiatry and Neurology, and hold a current state medical license as an MD or DO without restrictions, limitations, or sanctions from government programs. Payer/ Managed Care experience is heavily preferred. 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 is preferred, but not required. 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

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 Psychiatry specialty Is required.) Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs. For Behavioral Health only - Board certification by the American Board of Psychiatry and Neurology. Current state medical license without restrictions.

Pay Range

$215,000.00 - $408,500.00 per year

At Centene

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

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.

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.

Equal Opportunity

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.