Remote Medicare Medical Director

Centene Corporation; Missouri; Hybrid; USD 231,000 - 441,000; Full time

Job summary

A leading healthcare organization seeks a Clinical Professional to oversee medical management and quality improvement for diverse populations. This role requires a Medical Doctor or Doctor of Osteopathy with strong leadership skills and experience in utilization management. The position offers competitive compensation and benefits, including flexible work arrangements.

Benefits

Health insurance

401K

Tuition reimbursement

Paid time off

Flexible work arrangements

Qualifications

• Active medical practice as MD or DO required.
• Utilization management experience preferred.
• Board certification in a recognized specialty required.

Responsibilities

• Direct and coordinate medical management and quality improvement.
• Conduct medical review activities for utilization review.
• Collaborate with clinical teams and network providers.

Skills

Utilization management

Medical leadership

Quality improvement

Education

Medical Doctor or Doctor of Osteopathy

Coursework in health administration

Job description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits, including a fresh perspective on workplace flexibility.

Position Purpose:

Assist the Chief Medical Director in directing and coordinating the medical management, quality improvement, and credentialing functions for the business unit.

1. Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
2. Perform medical review activities related to utilization review, quality assurance, and review of complex, controversial, or experimental medical services, ensuring timely and quality decision-making.
3. Support the implementation of performance improvement initiatives for capitated providers.
4. Assist in planning and establishing goals and policies to improve quality and cost-effectiveness of care and services for members.
5. Provide medical expertise in the operation of quality improvement and utilization management programs, in compliance with regulatory, state, corporate, and accreditation standards.
6. Assist in the functioning of physician committees, including structure, processes, and membership.
7. Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
8. Collaborate with clinical teams, network providers, appeals teams, and consultants to review complex cases and medical necessity appeals.
9. Participate in provider network development and market expansion as appropriate.
10. Assist in developing and implementing physician education programs on clinical issues and policies.
11. Identify utilization review studies and evaluate adverse trends, provider practice patterns, and benefit/payment components.
12. Identify clinical quality improvement opportunities to reduce unwarranted practice variation and improve care quality and cost.
13. Interface with physicians and providers to facilitate implementation of recommendations that improve utilization and healthcare quality.
14. Review claims involving complex or unusual services to determine medical necessity and appropriate payment.
15. Develop alliances with the provider community through medical management programs.
16. Represent the business unit at state and national forums regarding medical philosophy and policies, as needed.
17. Participate in state committees and ad hoc groups.
18. Work weekends and holidays as required to support business operations.

Education and Experience:

Medical Doctor or Doctor of Osteopathy with active medical practice. Utilization management experience and knowledge of accreditation standards preferred. Coursework in health administration, financing, insurance, or personnel management is advantageous. Experience managing care for diverse populations is preferred.

Licenses and Certifications:

Board certification in a recognized specialty (e.g., Internal Medicine or Family Medicine). Current unrestricted state license as MD or DO.

Compensation and Benefits:

Pay Range: $231,900 - $440,500 annually. Benefits include competitive pay, health insurance, 401K, stock plans, tuition reimbursement, paid time off, holidays, and flexible work arrangements (remote, hybrid, field, or office).

Centene is committed to diversity and equal opportunity. All qualified applicants will be considered regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics. Applicants with criminal records will be considered in accordance with applicable laws.