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<div><p><b>Position Purpose:</b><br/>Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.</p><p></p><ul><li>Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.</li></ul><p></p><ul><li>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.</li></ul><p></p><ul><li>Supports effective implementation of performance improvement initiatives for capitated providers.</li></ul><p></p><ul><li>Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.</li></ul><p></p><ul><li>Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.</li></ul><p></p><ul><li>Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.</li></ul><p></p><ul><li>Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.</li></ul><p></p><ul><li>Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.</li></ul><p></p><ul><li>Participates in provider network development and new market expansion as appropriate.</li></ul><p></p><ul><li>Assists in the development and implementation of physician education with respect to clinical issues and policies.</li></ul><p></p><ul><li>Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.</li></ul><p></p><ul><li>Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.</li></ul><p></p><ul><li>Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.</li></ul><p></p><ul><li>Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.</li></ul><p></p><ul><li>Develops alliances with the provider community through the development and implementation of the medical management programs.</li></ul><p></p><ul><li>As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.</li></ul><p></p><ul><li>Represents the business unit at appropriate state committees and other ad hoc committees.</li></ul><p></p><ul><li>May be required to work weekends and holidays in support of business operations, as needed.</li></ul><p></p><p></p><p></p><p></p><p></p><p><br/><b>Education/Experience:</b></p><ul><li>Medical Doctor or Doctor of Osteopathy.</li><li>Utilization Management experience and knowledge of quality accreditation standards preferred.</li><li>Actively practices medicine.</li><li>Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.</li><li>Experience treating or managing care for a culturally diverse population preferred.</li></ul><p><br/><b>License/Certifications:</b></p><ul><li>Active 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.</li><li>Certification in Internal and / or Family Medicine specialty, preferred.</li><li>Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.<br/></li></ul><p></p><p></p>Pay Range: $236,500.00 - $449,300.00 per year<p></p><p>Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.</p><p></p></div>
