Behavioral Medical Director
| Company | Centene |
|---|---|
| Location | Washington, USA, Delaware, USA, South Carolina, USA, Georgia, USA, Concord, NH, USA, Mississippi, USA, Arkansas, USA, Northeastern United States, USA, Wisconsin, USA, Oklahoma, USA, Missouri, USA, Ohio, USA |
| Salary | $231900 – $440500 |
| Type | Full-Time |
| Degrees | JD |
| Experience Level | Senior, Expert or higher |
Requirements
- Medical Doctor or Doctor of Osteopathy
- Board certification by the American Board of Psychiatry and Neurology
- Current state medical license without restrictions as a MD or DO without restrictions, limitations, or sanctions from government programs
- Utilization Management experience and knowledge of quality accreditation standards preferred
- Actively practices medicine
- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous
- Experience treating or managing care for a culturally diverse population preferred
Responsibilities
- 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 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
- May be required to work weekends and holidays in support of business operations, as needed
Preferred Qualifications
- Utilization Management experience and knowledge of quality accreditation standards preferred
- Experience treating or managing care for a culturally diverse population preferred