Remote Medical Director: Quality & Utilization Leadership

Centene Corporation; Ohio; 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 plus holidays

Flexible work schedules (remote,Hybrid

Job summary

Centene Corporation seeks a Medical Director to lead utilization management, quality improvement, and medical review activities across complex services. The role focuses on timely decision making, cost containment, and adherence to accreditation standards while guiding physician committees and education initiatives.

The position involves collaborating with clinical teams, network providers, and appeals teams to optimize care quality for members.

Qualifications

• Medical doctor with active practice.
• Familiarity with utilization management and quality accreditation standards.
• Strong analytical and decision-making skills.
• Experience with diverse populations and healthcare systems.

Responsibilities

• Provide medical leadership for utilization management, cost containment, and quality improvement.
• Perform medical reviews for complex or experimental services to ensure timely decisions.
• Support performance improvement initiatives for capitated providers.
• Assist in planning goals and policies to improve care quality and cost-effectiveness.
• Oversee medical expertise in approved quality programs in line with regulatory standards.
• Coordinate with physician committees and leadership on medical policy.
• Conduct rounds to coordinate care for high-risk patients with care management teams.
• Collaborate with clinical teams, providers, and consultants for complex cases and appeals.
• Contribute to provider network development and new market expansion.
• Develop and implement physician education on clinical issues and policies.
• Identify utilization review studies and monitor trends and variations in care.
• Interface with providers to implement recommendations improving utilization and quality.
• Review complex or unusual claims to determine medical necessity and payment.
• Build alliances with providers through medical management programs.

Education

Medical Doctor or Doctor of Osteopathy

Job description

Centene Corporation seeks a Medical Director to lead utilization management, quality improvement, and medical review activities across complex services. The role focuses on timely decision making, cost containment, and adherence to accreditation standards while guiding physician committees and education initiatives.

The position involves collaborating with clinical teams, network providers, and appeals teams to optimize care quality for members.