Medical Director - UM Optimization

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

Benefits offered by this job

Competitive pay

Health insurance

401K/Stock plans

Tuition reimbursement

PTO & holidays

Flexible remote/hybrid/work model

Job summary

Centene is seeking a Medical Director for remote leadership of Utilization Management and quality improvement. The role focuses on strategic planning, data analysis, and process optimization while supporting the CMO and nursing leaders.

The ideal candidate holds an MD/DO with active licensure, board-certified in Psychiatry, and extensive payer/managed care experience. Availability for weekend/holiday coverage may be required.

Qualifications

• MD/DO licensed in the United States.
• Experience in utilization management and quality accreditation standards preferred.
• Board certification in Psychiatry is required.

Responsibilities

• Direct and coordinate medical management, quality improvement and credentialing for the business unit.
• Provide medical leadership for utilization management and cost containment.
• Review medical services for medical necessity and appropriate payment.
• Support performance improvement initiatives for capitated providers.
• Develop and implement physician education on clinical issues and policies.
• Collaborate with clinical teams, network providers and appeals teams on complex cases.

Skills

Utilization Management experience

Quality improvement

Education

Medical Doctor or Doctor of Osteopathy

Board certification in Psychiatry

Current state medical license (unrestricted)

Coursework in Health Administration/Health Financing/Insurance/Personnel Management

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 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 have 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. 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.

Pay Range:

$215,000.00 - $408,500.00 per year

About 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:

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• flexible approach to work with remote, hybrid, field or office work schedules
• Actual pay will be adjusted based on an individual's skills