Medical Director - Illinois

Meridian Illinois; Argenta (IL); Remote; USD 221,000 - 421,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Professional to assist the Chief Medical Director in directing medical management and quality improvement initiatives. This remote position involves collaboration with clinical teams and oversight of utilization management activities. Ideal candidates will hold a medical degree and possess experience in diverse healthcare settings. Competitive compensation and benefits are offered, emphasizing workplace flexibility.

Benefits

Health Insurance

401K

Stock Plans

Tuition Reimbursement

Paid Time Off

Flexible Work Arrangements

Qualifications

• Experience managing care for diverse populations preferred.
• Utilization Management experience and knowledge of accreditation standards preferred.

Responsibilities

• Direct and coordinate medical management, quality improvement, and credentialing functions.
• Provide medical expertise in quality improvement and utilization management programs.
• Collaborate with clinical teams for reviewing complex cases.

Skills

Utilization Management

Quality Improvement

Medical Leadership

Education

Medical Doctor

Doctor of Osteopathy

Job description

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. This position is REMOTE!

1. Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
2. Perform medical review activities related to utilization review, quality assurance, and review of complex, controversial, or experimental medical services, ensuring timely and quality decision-making.
3. Support effective implementation of performance improvement initiatives for capitated providers.
4. Assist the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
5. Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
6. Assist the Chief Medical Director in the functioning of physician committees, including structure, processes, and membership.
7. Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
8. Collaborate effectively with clinical teams, network providers, appeals teams, and medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
9. Participate in provider network development and new market expansion as appropriate.
10. Assist in developing and implementing physician education regarding clinical issues and policies.
11. Identify utilization review studies and evaluate adverse trends in utilization, unusual provider practices, and benefit/payment adequacy.
12. Identify clinical quality improvement studies to reduce unwarranted variation in practice, thereby improving quality and cost of care.
13. Interface with physicians and providers to facilitate implementation of recommendations to improve utilization and healthcare quality.
14. Review claims involving complex, controversial, or new services to determine medical necessity and appropriate payment.
15. Develop alliances with the provider community through medical management programs.
16. Represent the business unit before various publics and committees as needed.
17. May work weekends and holidays to support business operations.
18. Consult on MCO clinical policy related to Substance Use Disorders and individual member cases for the MCM program.
19. Perform other duties as assigned and comply with all policies and standards.

Education/Experience:

Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of accreditation standards preferred. Actively practices medicine. Coursework in Health Administration, Financing, Insurance, or Personnel Management is advantageous. Experience managing care for diverse populations is preferred.

License/Certifications:

Board certification in a recognized medical specialty and a current Illinois state license as an MD or DO without restrictions or sanctions. For Illinois plan only: Must reside in Illinois and have at least 8 years of experience in mental health, substance abuse, or children's health services.

Compensation & Benefits:

Pay Range: $221,300.00 - $420,500.00 per year. Benefits include competitive pay, health insurance, 401K, stock plans, tuition reimbursement, paid time off, holidays, and flexible work arrangements including remote, hybrid, field, or office schedules. Actual pay will be adjusted based on skills, experience, and other factors. Total compensation may include additional incentives.

Equal Opportunity Statement:

Centene is an equal opportunity employer committed to diversity. All qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics. Applicants with arrest or conviction records will be considered in accordance with applicable laws.