远程全国医学总监
Remote National Medical Director
职位职责：
协助首席医疗总监指导和协调业务单元的医疗管理、质量改进和资质认证职能。
· 为所有资源管理、成本控制和医疗质量改进活动提供医疗领导。
· 执行与资源审查、质量保证和复杂、有争议或实验性医疗服务的医疗审查相关的活动，确保及时和高质量的决策。
· 支持对按人头付费提供者实施绩效改进计划。
· 协助首席医疗总监制定和建立目标及政策，以提高会员的护理和服务质量和成本效益。
· 在符合监管、州、公司和认证要求的前提下，提供有关批准的质量改进和资源管理项目运作的医疗专业知识。
· 协助首席医疗总监运作医生委员会，包括委员会结构、流程和成员。
· 定期进行查房，评估和协调高风险患者的护理，与护理管理团队合作以优化结果。
· 与临床团队、网络提供者、申诉团队、医疗和药学顾问有效协作，审查复杂病例和医疗必要性申诉。
· 根据需要参与供应商网络开发和新市场扩展。
· 协助制定和实施有关临床问题和政策的医生教育。
· 识别资源审查研究，评估医疗服务质量使用中的负面趋势、异常供应商实践模式以及福利/支付组成部分的充分性。
· 识别临床质量改进研究，以帮助减少临床实践中的不合理差异，从而提高护理质量和成本效益。
· 与医生和其他提供者进行沟通，以促进向提供者实施可改善资源利用和医疗质量的建议。
· 审查涉及复杂、有争议或新服务的索赔，以确定医疗必要性和适当的支付。
· 通过制定和实施医疗管理计划，与供应商社区建立合作关系。
· 在需要时，代表业务单元在各种公众场合，包括本地场合进行沟通。
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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.
- Active 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
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Originally posted on Himalayas