Senior Medical Director - Quality & Utilization Leadership

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

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work schedules

Job summary

Centene Corporation seeks an experienced physician leader to assist the Chief Medical Director in directing medical management, quality improvement, and credentialing for the business unit. You will lead utilization management, cost containment, and quality initiatives, perform specialized medical reviews, and guide performance improvements for capitated providers.

You will collaborate with clinical teams, network providers, and consultants to review complex cases, support education, and advance

Qualifications

• Medical Doctor or Doctor of Osteopathy is required.
• 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

• Assist the Chief Medical Director to direct and coordinate medical management, quality improvement and credentialing functions for the business unit.
• Provide medical leadership of utilization management, cost containment, and medical quality improvement activities.
• Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex or experimental services.
• Support performance improvement initiatives for capitated providers.
• Assist in planning and establishing goals and policies to improve quality and cost-effectiveness of care for members.
• Provide medical expertise in approved quality improvement and utilization management programs in accordance with requirements.
• Assist in physician committees' functioning and processes.
• Conduct regular rounds to assess and coordinate care for high-risk patients.
• Collaborate with clinical teams, network providers, appeals team, and consultants for reviewing complex cases.
• 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 trends in utilization and adverse variations.
• Identify clinical quality improvement studies to reduce unwarranted variation in practice.
• Interface with physicians to implement recommendations.
• Review claims involving complex services to determine medical necessity and payment.
• Develop alliances with the provider community through medical management programs.
• Represent the business unit before publics on medical philosophy and policies.
• Represent the business unit at state committees and ad hoc committees.
• May require weekend/holiday work as needed.

Education

Medical Doctor or Doctor of Osteopathy

Job description

Centene Corporation seeks an experienced physician leader to assist the Chief Medical Director in directing medical management, quality improvement, and credentialing for the business unit. You will lead utilization management, cost containment, and quality initiatives, perform specialized medical reviews, and guide performance improvements for capitated providers.

You will collaborate with clinical teams, network providers, and consultants to review complex cases, support education, and advance