Senior Medical Director Medicare

Centene; United States; Remote; USD 231,000 - 441,000; Full time

Job summary

A leading company is seeking a Clinical Professional to assist in developing and implementing clinical strategies for Medicare. The role involves providing medical leadership, overseeing quality improvement activities, and engaging with providers to enhance clinical outcomes. Competitive benefits and a flexible work environment are offered, with a pay range reflecting the skills and experience of the candidate.

Benefits

Health Insurance

401K

Stock Plans

Tuition Reimbursement

Paid Time Off

Holidays

Flexible Work Arrangements

Qualifications

• 7+ years of clinical practice required.
• Management experience preferred.
• Active medical practice required.

Responsibilities

• Articulate clinical strategy to business executives.
• Provide medical leadership for various management activities.
• Support performance improvement initiatives.

Skills

Leadership

Utilization Management

Clinical Strategy

Regulatory Compliance

Education

Medical Doctor or Doctor of Osteopathy

MBA or JD

Tools

PowerPoint

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 Medicare Chief Medical Officer to develop and implement our enterprise clinical strategy. WellCare serves over 1M members nationwide, of which 40% are dual members. The individual will serve as a key stakeholder to improve STARS performance, optimize the denial and appeals process, and support provider engagement efforts nationwide. The individual will also architect an integrated duals strategy that meets regulatory requirements while improving clinical outcomes.

Responsibilities:

1. Articulate clinical strategy to business executives and demonstrate ROI behind clinical initiatives. Understand Medicare and Medicaid; prior health plan experience is required.
2. Provide medical leadership for utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement activities.
3. Support performance improvement initiatives for capitated providers.
4. Assist in planning and establishing goals to improve quality and cost-effectiveness of care.
5. Provide medical expertise for quality improvement and utilization management programs, ensuring compliance with regulatory and accreditation standards.
6. Assist in physician committee functions, including structure, processes, and membership.
7. Oversee activities of physician advisors and medical directors.
8. Utilize medical and pharmacy consultants for complex case reviews and appeals.
9. Participate in provider network development and market expansion.
10. Engage in provider profiling and physician education on clinical issues and policies.
11. Design and evaluate population health studies and program evaluations.
12. Excel in PowerPoint; evaluate vendors; attend JOCs with PCP groups and partners.
13. Identify and evaluate utilization review studies and adverse trends.
14. Identify clinical quality improvement opportunities to reduce unwarranted practice variation.
15. Interface with providers to implement utilization and quality recommendations.
16. Review complex claims for medical necessity and payment accuracy.
17. Develop provider alliances through medical management programs.
18. Represent the business unit on medical philosophy, policies, and issues at public forums and committees.
19. Oversee Appeals and Denials department as needed, including policies and personnel.
20. Perform other duties and comply with policies and standards.

Education and Experience:

Medical Doctor or Doctor of Osteopathy with 7+ years of clinical practice. Management experience and utilization management knowledge preferred. Active medical practice required. Coursework in health administration, financing, insurance, or personnel management is advantageous. Experience with diverse populations is preferred. An MBA or JD is a plus.

Licenses and Certifications:

Board certification in a recognized medical specialty (psychiatry required). Current unrestricted MD or DO license in the state.

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. Actual pay depends on skills, experience, and other factors. Total compensation may include incentives.

Equal Opportunity Statement:

Centene is committed to diversity and equal employment opportunity. All qualified applicants will be considered regardless of protected characteristics. Applicants with arrest or conviction records will be considered per applicable laws.

About the Company:

Centene Corporation, based in St., is a publicly traded managed care company.