Remote Inpatient Medicare Medical Director

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

Benefits offered by this job

Health insurance

401K and stock plans

Tuition reimbursement

Job summary

Centene Corporation is seeking a physician leader to drive utilization management, quality improvement, and medical cost containment. You will review complex cases, work with care teams, and guide policy decisions to enhance patient outcomes.

The role requires active medical practice and board-certified credentials. The position offers leadership across medical management programs, with opportunities to influence provider networks and market expansion.

Qualifications

• MD or DO with board certification in a medical specialty
• Experience in utilization management and quality accreditation standards preferred
• Active practice of medicine and culturally competent care

Responsibilities

• Provide medical leadership for utilization management, cost containment, and medical quality improvement
• Perform medical reviews for utilization review and quality assurance to ensure timely decisions
• Support performance improvement initiatives for capitated providers
• Assist in planning goals/policies to improve care quality and cost-effectiveness
• Represent the medical unit with physician committees and state/national bodies
• Coordinate care for high-risk patients with care management teams
• Collaborate with clinical teams and providers on complex cases and appeals
• Contribute to provider network development and market expansion
• Develop and implement physician education on clinical issues and policies
• Identify and evaluate utilization trends and adverse patterns
• Interface with providers to implement recommendations improving utilization and care quality
• Review claims involving complex or new services for medical necessity and payment
• Develop alliances with the provider community via medical management programs
• May represent the business unit publicly on medical policy issues
• May work weekends/holidays as needed

Skills

Utilization management

Quality improvement

Medical leadership

Education

MD/DO

Healthcare administration coursework

Job description

Position Purpose

• 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.
• Active Certification in Internal or Family Medicine, Preferred.
• 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

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.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act