Company: Centene Corporation
Location: Saint Charles
Posted on: November 6, 2019
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
- 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
- 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
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
License/Certifications: Board Certification through American Board
Medical Specialties. Current state medical license without
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.
Keywords: Centene Corporation, Saint Charles , Medical Director, Executive , Saint Charles, Missouri
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