Medical Director: Utilization and Quality Improvement

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

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements

Job summary

Centene Corporation is seeking a Board Certified Physician licensed in Georgia to lead medical management, quality improvement, and credentialing for the business unit. The role directs utilization management and clinical review activities, supports performance improvements, and collaborates with clinical teams and providers to optimize care and cost-effectiveness.

Requirements include MD/DO with board certification in a medical specialty, GA license, and active clinical practice.

Qualifications

• Medical Doctor or Doctor of Osteopathy with active practice.
• Utilization Management experience and knowledge of quality accreditation standards preferred.
• Actively practices medicine.
• Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management advantageous.
• Experience treating or managing care for a culturally diverse population preferred.

Responsibilities

• Provides medical leadership of utilization management, cost containment, and medical quality improvement activities.
• Performs medical review activities pertaining to utilization review and quality assurance.
• Supports performance improvement initiatives for capitated providers.
• Assists in planning goals and policies to improve quality and cost-effectiveness of care.
• Provides medical expertise in approved quality improvement and utilization management programs.
• Assists in physician committee operations and membership.
• Regular rounds to assess and coordinate care for high-risk patients with care management teams.
• Collaborates with clinical teams, network providers, appeals team and consultants on complex cases.
• Participates in provider network development and market expansion as appropriate.
• Participates in physician education regarding clinical issues and policies.
• Identifies utilization review studies and evaluates trends in utilization and payment components.
• Identifies quality improvement studies to reduce variation and improve quality and cost.
• Interfaces with physicians/providers to implement recommendations.
• Reviews complex claims to determine medical necessity and payment.
• Develops alliances with provider community through medical management programs.
• May represent the business unit before publics and state committees.
• Represents the business unit at state and ad hoc committees.
• May work weekends and holidays as needed.

Skills

Medical leadership

Utilization management

Quality improvement

Clinical review

Regulatory knowledge

Team collaboration

Education

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

Job description

Centene Corporation is seeking a Board Certified Physician licensed in Georgia to lead medical management, quality improvement, and credentialing for the business unit. The role directs utilization management and clinical review activities, supports performance improvements, and collaborates with clinical teams and providers to optimize care and cost-effectiveness.

Requirements include MD/DO with board certification in a medical specialty, GA license, and active clinical practice.