Remote Medical Director - Quality & Utilization Leader

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

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible work arrangements (remote/hyb

Job summary

Centene Corporation seeks a Senior Medical Director to lead medical management, quality improvement and credentialing for the business unit. You will provide medical leadership for utilization management and cost containment, and ensure high-quality decision making across programs.

The role requires collaboration with care teams, physician committees, network providers and consultants to review complex cases and maintain regulatory and accreditation standards.

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

• Provide medical leadership for utilization management and quality improvement.
• Perform medical review activities for utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
• Support performance improvement initiatives for capitated providers.
• Assist in planning goals to improve quality and cost-effectiveness of care and service for members.
• Ensure compliance with regulatory, state, corporate, and accreditation requirements.
• Assist the Chief Medical Director in the functioning of physician committees including structure, processes, and membership.
• Coordinate care for high-risk patients with care management teams to optimize outcomes.
• Collaborate with clinical teams, network providers, appeals team, medical and pharmacy consultants on reviews.
• Participate in provider network development and new market expansion as appropriate.
• Assist in physician education regarding clinical issues and policies.
• Identify utilization review studies and evaluate adverse trends in utilization of medical services.
• Identify clinical quality improvement studies to reduce unwarranted variation in practice to improve quality and cost of care.
• Interface with physicians to implement recommendations to improve utilization and health care quality.
• Review claims involving complex or unusual services to determine medical necessity and payment.

Skills

Medical leadership

Utilization management

Quality improvement

Clinical collaboration

Education

Medical Doctor or Doctor of Osteopathy

Job description

Centene Corporation seeks a Senior Medical Director to lead medical management, quality improvement and credentialing for the business unit. You will provide medical leadership for utilization management and cost containment, and ensure high-quality decision making across programs.

The role requires collaboration with care teams, physician committees, network providers and consultants to review complex cases and maintain regulatory and accreditation standards.