Behavioral Health Medical Director - UM Optimization

Centene; United States; Remote; USD 215,000 - 409,000; Full time

Job summary

Centene is seeking a Medical Director (Remote BH) to lead utilization management, quality improvement, and credentialing for the business unit. The role supports the CMO and works with nursing leaders to optimize UM processes and strategic planning, requiring psychiatry board certification and an unrestricted license.

Ideal candidates have UM experience and payer/managed care exposure, with a focus on data-driven decision making and improving care quality and cost-effectiveness for members.

Qualifications

• Board-certified in Psychiatry and current state MD/DO license.
• Utilization Management experience and knowledge of quality accreditation standards preferred.
• Active medical practice preferred, but not required.
• Payer/Managed Care experience is heavily preferred.

Responsibilities

• Provide medical leadership for utilization management, cost containment, and quality improvement.
• Perform medical review activities pertaining to utilization review and quality assurance for complex cases.
• Support physician education and coordinate with care management teams to optimize outcomes.
• Assist in planning goals and policies to improve care quality and cost-effectiveness for members.
• Represent the business unit on state committees and in ad hoc committees as needed.

Skills

Utilization Management

Education

Medical Doctor (MD) or Doctor of Osteopathy (DO)

Board certification in Psychiatry

Current state license as MD or DO

Job description

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, 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.

Centene offers