Remote Medical Director: Quality & Utilization Leadership

Centene Corporation; Maine; Hybrid; USD 237,000 - 449,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

PTO and holidays

Job summary

Centene Corporation seeks a physician leader to assist the Chief Medical Director in directing medical management, quality improvement, and credentialing for the business unit. You will provide medical leadership for utilization management, quality improvement, and cost containment while coordinating with care teams and network providers to ensure high-quality, cost-effective care.

The role involves reviews of complex or controversial cases, participation in physician education, and

Qualifications

• Medical doctor or DO
• Experience in utilization management and knowledge of accreditation standards preferred
• Active medical practice
• Course work in health administration/financing/insurance or personnel management is advantageous
• Experience treating or managing a culturally diverse population preferred

Responsibilities

• Assist the Chief Medical Director to direct and coordinate 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 related to utilization review, quality assurance, and medical review of complex or experimental services with timely decisions.
• Support performance improvement initiatives for capitated providers.
• Assist in planning goals and policies to improve quality and cost-effectiveness of care for members.
• Provide medical expertise in quality improvement and utilization management programs in accordance with regulatory and accreditation requirements.
• Assist in functioning of physician committees including structure, processes and membership.
• Conduct rounds to assess and coordinate care for high-risk patients with care management teams to optimize outcomes.
• Collaborate with clinical teams, network providers, appeals team, and consultants for complex cases and medical necessity appeals.
• Participate in provider network development and new market expansion as appropriate.
• Assist in physician education on clinical issues and policies.
• Identify utilization review studies and evaluate adverse trends and adequacy of benefits/payments.
• Identify clinical quality improvement studies to reduce unwarranted variation and improve quality and cost of care.
• Interface with physicians to implement recommendations for better utilization and health care quality.
• Review claims involving complex or new services to determine medical necessity and payment.
• Develop alliances with the provider community through medical management programs.
• Represent the business unit before publics and state committees as needed.
• May work weekends and holidays to support operations.

Job description

Centene Corporation seeks a physician leader to assist the Chief Medical Director in directing medical management, quality improvement, and credentialing for the business unit. You will provide medical leadership for utilization management, quality improvement, and cost containment while coordinating with care teams and network providers to ensure high-quality, cost-effective care.

The role involves reviews of complex or controversial cases, participation in physician education, and