Medical Director
职位目的：协助首席医疗总监指导和协调业务单位的医学管理，质量改善和认证功能。关键细节：必须是董事会认可的医生，并获得亚利桑那州执照。· 为利用管理，成本控制和医疗质量提高活动提供所有人的医疗领导力。·执行有关使用审查，质量保证和复杂，有争议或实验性的医疗服务的医疗检查活动，确保及时和质量的决策。·支持资本供应商有效实施绩效改进倡议。· 协助首席医务主任规划，制定目标和政策以提高关怀与服务的质量和成本效益。· 根据监管，州，企业和认证要求提供批准的质量改善和利用管理计划运行中的医学专业知识。· 帮助首席医疗主任在委员会结构，流程和成员身份等委员会的运作中。· 定期进行评估和协调高风险患者的护理，并与护理管理团队合作优化结果。· 与临床团队，网络提供商，上诉团队，医疗和药房顾问进行复杂的案件和医疗需求上诉的审查。· 根据需要参与供应商网络发展和新市场扩张。· 在临床问题和政策方面协助制定和实施医生教育。·确定利用情况评估研究并评估使用医疗服务的不利趋势，不寻常的提供者实践模式以及福利/支付组件的充分性。· 确定临床质量改善研究，以帮助减少临床实践中不合理的变化，以提高护理质量和成本。· 与医生和其他提供商进行互通，以促进对服务提供者提出建议的实施，从而改善利用率和卫生保健质量。·审查涉及复杂，有争议或异常或新服务的索赔，以确定医疗需求和适当支付。·通过开发和实施医疗管理来与提供商社区建立联盟。
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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.
Key Details: Must be a Board Certified Physician and licensed in the state of Arizona.
· 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.
- Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.
Pay Range: $225,700.00 - $428,900.00 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