Job Description

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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 in directing and coordinating the medical management, quality improvement, and credentialing functions for the business unit.

Responsibilities include:

1. Providing medical leadership for utilization management, cost containment, and quality improvement activities.
2. Performing medical reviews related to utilization review, quality assurance, and complex or controversial medical services, ensuring timely and quality decisions.
3. Supporting performance improvement initiatives for capitated providers.
4. Helping establish goals and policies to improve quality and cost-effectiveness of care.
5. Ensuring compliance with regulatory, state, corporate, and accreditation requirements in quality improvement and utilization management programs.
6. Participating in physician committees and overseeing their structure, processes, and membership.
7. Conducting rounds to assess and coordinate care for high-risk patients, collaborating with care management teams.
8. Collaborating with clinical teams, network providers, and other stakeholders for case reviews and appeals.
9. Participating in provider network development and market expansion.
10. Developing and implementing physician education programs on clinical issues and policies.
11. Identifying utilization review studies and evaluating trends and provider practices.
12. Identifying clinical quality improvement opportunities to enhance care quality and reduce costs.
13. Facilitating implementation of recommendations to providers to improve utilization and quality.
14. Reviewing claims involving complex or unusual services for medical necessity and payment accuracy.
15. Developing alliances with providers through medical management programs.
16. Representing the business unit at public forums and committees as needed.
17. Working weekends and holidays as required to support operations.

Education/Experience:

Medical Doctor or Doctor of Osteopathy with utilization management experience and knowledge of accreditation standards. Active medical practice required. Coursework in health administration, financing, insurance, or personnel management is advantageous. Experience with diverse populations preferred.

License/Certifications:

Board certification in a recognized medical specialty and a current, unrestricted California medical license (MD or DO).

Additional Details:

Pay Range: $231,900.00 - $440,500.00 per year

Centene offers comprehensive benefits including competitive pay, health insurance, 401K, stock plans, tuition reimbursement, paid time off, and flexible work arrangements. Actual pay depends on skills, experience, and education. Total compensation may include incentives.

Centene is an equal opportunity employer committed to diversity. All qualified applicants will be considered without regard to protected characteristics. Applicants with criminal records will be considered in accordance with applicable laws.

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