Remote Director, Medical Quality & Utilization

Centene Corporation; California (MO); On-site; USD 237,000 - 449,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Job summary

Centene Corporation seeks a physician leader to direct medical management, QA and credentialing for a business unit. The role provides medical leadership for utilization management, cost containment and quality improvement activities, and supports performance initiatives for capitated providers.

The position involves planning goals, regulatory compliance, and active participation in physician committees. Regular rounds and collaboration with care teams aim to optimize outcomes and prudent

Qualifications

• Medical Doctor or Doctor of Osteopathy; 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 is advantageous.
• Experience treating or managing care for a culturally diverse population preferred.

Responsibilities

• Direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
• Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
• Perform 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.
• Support effective implementation of performance improvement initiatives for capitated providers.
• Assist Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provide 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.

Skills

Medical leadership

Utilization management

Quality improvement

Provider collaboration

Regulatory compliance

Education

Medical Doctor or Doctor of Osteopathy

Job description

Centene Corporation seeks a physician leader to direct medical management, QA and credentialing for a business unit. The role provides medical leadership for utilization management, cost containment and quality improvement activities, and supports performance initiatives for capitated providers.

The position involves planning goals, regulatory compliance, and active participation in physician committees. Regular rounds and collaboration with care teams aim to optimize outcomes and prudent