Medical Director - Columbus, OH

Job description

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

  • 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. 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. Oversees the activities of physician advisors. Utilizes the services of 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
Qualifications:

Education/Experience: Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine). The candidate must be an actively practicing physician. Previous experience within a managed care organization is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred. Experience treating or managing care for a culturally diverse population preferred.

License/Certifications: Board Certification through American Board Medical Specialties. Current state medical license without restrictions.

For Behavioral Health only - Board certification by the American Board of Psychiatry and Neurology. Current state medical license without restrictions.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Employee Status:
Regular
Job Level:
Director/Sr. Director
Job Type:
Regular
More information about the job
Is Relocation Available?
Yes, nationwide
Is there a bonus structure?
20% or higher
Are you open to sponsorship?
No
This position is:
New Position
Is there a possibility to work remote?
No
Is there equity?
No
Are there flexible work hours?
No
Does this position have direct reports?
No
Who does this position report to?
reports to VP, Medical Affairs Update 4/2 - this role can be part-time or full time. Please include details of the candidate preference in the recruiter notes of your submittal.
What are the 3-4 non-negotiable requirements on this position?
Board certified - Psychiatry Utilization management
What are the nice-to-have skills?
please submit question and answer in the recruiter notes section of submittal: How many total years of experience does the candidate have as a Practicing Physician? How often do they practice and in what capacity? List all states with a current Medical license? How many years of experience does this candidate have in a Medical Director role? Does the candidate have experience working at a Health Plan? If so, how many years total experience? If the candidate does not have experience working for a Health Plan, why are they interested in making the change? Explain the candidate’s experience working with the Medicaid Population? Is Relocation needed? If so, what is their current location? Is the candidate willing to travel to field offices and other health plans as needed? What is the current total compensation package? (Base, bonus structure, commission structure, deferred income/vesting, pension, car/allowance): Does this candidate have an active non-compete?

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