Medical Director, Appeals
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Job Description
Medical Director reviewing complex healthcare appeals and guiding utilization management for Centene. Improving care quality, cost-effectiveness, and provider performance.
Responsibilities:
- Assist the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions
- Provide medical leadership for utilization management, cost containment, and medical quality improvement activities
- Perform medical reviews involving utilization review, quality assurance, and complex, controversial, experimental, unusual, or new medical services
- Conduct regular rounds to assess and coordinate care for high-risk patients
- Collaborate with care management teams, clinical teams, network providers, appeals teams, and medical and pharmacy consultants
- Support performance improvement initiatives for capitated providers
- Assist with planning goals and policies to improve quality and cost-effectiveness of care
- Provide medical expertise for quality improvement and utilization management programs
- Assist with physician committees, including structure, processes, and membership
- Participate in provider network development and new market expansion
- Support physician education on clinical issues and policies
- Identify utilization review and clinical quality improvement studies and evaluate adverse utilization trends
- Facilitate recommendations to providers to improve utilization and healthcare quality
- Review complex claims to determine medical necessity and appropriate payment
- Develop provider-community alliances through medical management programs
- Represent the business unit before public, state, and ad hoc committees as needed
Requirements:
- Medical Doctor or Doctor of Osteopathy
- Actively practices medicine
- 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
- Utilization Management experience and knowledge of quality accreditation standards preferred
- Certification in Internal or Family Medicine preferred
- Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management advantageous
- Experience treating or managing care for a culturally diverse population preferred
- May be required to work weekends and holidays in support of business operations
Benefits:
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Competitive pay
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