Medical Director, Appeals
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Job Description
Medical Director supporting Centene’s healthcare operations through utilization management, quality improvement, and complex medical appeals. Directing provider collaboration and care optimization across designated remote states.
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 review for utilization review, quality assurance, and complex, controversial, or experimental medical services
- Support performance improvement initiatives for capitated providers
- Assist with goals and policies to improve quality and cost-effectiveness of care and service
- Provide medical expertise for quality improvement and utilization management programs meeting regulatory, state, corporate, and accreditation requirements
- Assist with physician committees, including structure, processes, and membership
- Conduct regular rounds for high-risk patients and collaborate with care management teams
- Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on complex cases and medical necessity appeals
- Participate in provider network development and new market expansion
- Assist with physician education regarding clinical issues and policies
- Identify utilization review and clinical quality improvement studies
- Evaluate adverse utilization trends, unusual provider practice patterns, and benefit/payment adequacy
- Interface with physicians and providers to implement recommendations improving utilization and healthcare quality
- Review complex, controversial, unusual, or new-service claims for medical necessity and appropriate payment
- Develop provider-community alliances through medical management programs
- Represent the business unit before public audiences, state committees, 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, as needed
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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