Job Description

2 days ago Be among the first 25 applicants 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 to direct and coordinate the medical management, quality improvement, and credentialing functions for the business unit. Provide medical leadership for utilization management, cost containment, and medical quality improvement activities. 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. Support effective implementation of performance improvement initiatives for capitated providers. Assist the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and services for members. Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assist in the functioning of physician committees, including structure, processes, and membership. Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. Collaborate effectively with clinical teams, network providers, appeals teams, and medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participate in provider network development and new market expansion as appropriate. Assist in developing and implementing physician education regarding clinical issues and policies. Identify utilization review studies and evaluate adverse trends in utilization of medical services, provider practice patterns, and benefit/payment components. Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice, aiming to improve quality and cost of care. Interface with physicians and providers to facilitate implementation of recommendations to improve utilization and healthcare quality. Review claims involving complex or unusual services to determine medical necessity and appropriate payment. Develop alliances with the provider community through medical management programs. Represent the business unit before various publics and state committees on medical philosophy, policies, and related issues, as needed. May be required to work weekends and holidays to support business operations. Education/Experience Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of accreditation standards preferred. Active medical practice required. Coursework in Health Administration, Health Financing, Insurance, or Personnel Management is advantageous. Experience with culturally diverse populations preferred. License/Certifications Board certification by the American Board of Psychiatry and Neurology. Current unrestricted state medical license as MD or DO. Pay Range: $231,900.00 - $440,500.00 per year Centene offers comprehensive benefits including competitive pay, health insurance, 401K, stock purchase plans, tuition reimbursement, paid time off, holidays, and flexible work arrangements. Actual pay will be adjusted based on skills, experience, and other factors. Total compensation may include additional incentives. Centene is an equal opportunity employer committed to diversity. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics. #J-18808-Ljbffr Centene Corporation

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