About this opportunity
Centene Corp. lists this Remote Medical Director, Pharmacy opportunity in northern, Kentucky. Review the employer’s description below for duties, qualifications and application requirements.
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, 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. **Education/Experience:*** Medical Doctor or Doctor of Osteopathy.* 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.**License/Certifications:*** 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.* Certification in Internal or Family Medicine, preferred.* Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.Pay Range: $236,500.00 - $449,300.00 per year
#J-18808-Ljbffr
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.