Director of Medical Quality & Utilization (Remote)

Centene Corporation; Pennsylvania; Hybrid; USD 215,000 - 409,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock plans

Tuition reimbursement

Job summary

Centene Corporation is seeking a Medical Director to assist the Chief Medical Director in directing medical management, quality improvement, and credentialing for the business unit. The role leads utilization management, reviews complex medical cases, and collaborates with clinical teams and providers.

The position supports performance improvement initiatives, policy development, and education for physicians, with potential weekend/holiday coverage as needed.

Qualifications

• MD/DO licensed and actively practicing.
• Utilization Management experience and knowledge of quality accreditation standards.
• Active medical practice.
• Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management.
• Experience managing care for a culturally diverse population.

Responsibilities

• Direct and coordinate medical management, quality improvement, and credentialing functions.
• Provide medical leadership for utilization management, cost containment, and quality improvement.
• Perform medical review activities for utilization review, quality assurance, and medical review of complex or experimental services.
• Support implementation of performance improvement initiatives for capitated providers.
• Plan and establish goals and policies to improve quality and cost-effectiveness of care.
• Develop and implement physician education on clinical issues and policies.
• Identify utilization review studies and adverse trends to improve quality and cost of care.
• Interface with physicians and providers to implement recommendations that improve utilization and quality.
• Review claims involving complex or unusual services to determine medical necessity and payment.
• Represent the business unit before committees and publics as needed.

Skills

Utilization management leadership

Quality improvement processes

Medical review

Provider network collaboration

Education

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

Utilization Management experience and quality accreditation

Active medical practice

Course work in Health Administration/Health Financing/Insurance/Personnel Management

Experience with culturally diverse populations

Job description

Centene Corporation is seeking a Medical Director to assist the Chief Medical Director in directing medical management, quality improvement, and credentialing for the business unit. The role leads utilization management, reviews complex medical cases, and collaborates with clinical teams and providers.

The position supports performance improvement initiatives, policy development, and education for physicians, with potential weekend/holiday coverage as needed.