Centene
RemoteNationalMedicalDirector
Neural analysis suggests this role is
optimal for Senior candidates.
“Remote National Medical Director at Centene. Skills: Medical leadership, Medical expertise, Clinical quality improvement. 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.”
What You'll Achieve.
optimize outcomes; improve quality and cost-effectiveness of care and service for members; reduce unwarranted variation in clinical practice in order to improve the quality and cost of care
Industry & Context.
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.
May be required to work weekends and holidays in support of business operations, as needed.
What They're Looking For.
Must Have
Medical Doctor or Doctor of Osteopathy, Active state license as a MD or DO without restrictions, limitations, or sanctions from government programs, 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
Nice to Have
Utilization Management experience, Knowledge of quality accreditation standards, Active American Board Certification in Internal or Family Medicine
What You'll Do.
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
and medical quality improvement activities.
Performs medical review activities pertaining to utilization review
and medical review of complex
or experimental medical services
ensuring timely and quality decision making.
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
and accreditation requirements.
Assists the Chief Medical Director in the functioning of the physician committees including committee structure
Conduct regular rounds to assess and coordinate care for high-risk patients
collaborating with care management teams to optimize outcomes.
Collaborates effectively with clinical teams
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
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.
may represent the business unit before various publics both locally and nationally on medical philosophy
Represents the business unit at appropriate state committees and other ad hoc committees.
How You'll Work.
Team & Collaboration
Collaborating with care management teams to optimize outcomes.; Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.; Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.; Develops alliances with the provider community through the development and implementation of the medical management programs.
Full Job Description
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. * 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, ensuring timely and quality decision making. * 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. * Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. * Collaborates effectively with clinical teams, network providers, appeals team, 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 me
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