Medical Director

Business Area: Clinical & Care Management

Job Type: Full time

Position

Purpose:

Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

Key Details: Must be a Board Certified Physician and licensed in the state of Arizona.

• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.

• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.

• Supports effective implementation of performance improvement initiatives for capitated providers.

• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.

• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.

• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.

• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.

• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.

• Participates in provider network development and new market expansion as appropriate.

• Assists in the development and implementation of physician education with respect to clinical issues and policies.

• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.

• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.

• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.

• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.

• Develops alliances with the provider community through the development and implementation of the medical management programs.

• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.

• Represents the business unit at appropriate state committees and other ad hoc committees.

• May be required to work weekends and holidays in support of business operations, as needed.

Education/

Experience:

• Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred.

• Actively practices medicine.

• Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.

• Experience treating or managing care for a culturally diverse population preferred.

License/

Certifications:

• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.

• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Pay Range: $ - $ per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges…