Eastern Region Behavioral Medical Director — Utilization & Quality

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

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work arrangements

Job summary

Centene Corporation in the United States seeks a Medical Director to provide medical leadership across utilization management, cost containment, and quality improvement for members. You will review complex or experimental services, support performance improvement initiatives, and collaborate with physicians, care management teams, and network providers to ensure medical necessity and appropriate payment.

This role may require weekend or holiday coverage and offers comprehensive benefits and

Qualifications

• Medical Doctor or Doctor of Osteopathy required.
• Utilization Management experience and knowledge of accreditation standards preferred.
• Active medical practice required.
• Course work in Health Administration, Health Financing, Insurance or Personnel Management is advantageous.
• Experience treating or managing care for culturally diverse populations preferred.

Responsibilities

• Provide medical leadership for utilization management, cost containment and quality improvement.
• Perform medical reviews for utilization review, quality assurance, and complex services ensuring timely decisions.
• Assist Chief Medical Director in policy planning to improve quality and cost-effectiveness of care.
• Lead physician committees, structure and membership coordination.
• Coordinate care for high-risk patients with care management teams to optimize outcomes.
• Collaborate with clinical teams, network providers, appeals team and consultants on complex cases and medical necessity appeals.
• Support provider network development and new market expansion.
• Develop and implement physician education on clinical issues and policies.
• Identify utilization review studies and monitor trends to improve care quality and cost.

Skills

Utilization management

Quality improvement

Medical leadership

Clinical collaboration

Education

MD/DO

Job description

Centene Corporation in the United States seeks a Medical Director to provide medical leadership across utilization management, cost containment, and quality improvement for members. You will review complex or experimental services, support performance improvement initiatives, and collaborate with physicians, care management teams, and network providers to ensure medical necessity and appropriate payment.

This role may require weekend or holiday coverage and offers comprehensive benefits and