Job Description

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You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:

Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement, and credentialing functions for the business unit.

Responsibilities:

1. Provide medical leadership for utilization management, cost containment, and quality improvement activities.
2. Perform medical review activities related to utilization review, quality assurance, and complex or controversial medical services, ensuring timely decisions.
3. Support performance improvement initiatives for capitated providers.
4. Assist in planning and establishing goals and policies to improve quality and cost-effectiveness of care.
5. Provide medical expertise in quality improvement and utilization management programs, complying with regulations and accreditation standards.
6. Assist in physician committee operations, including structure, processes, and membership.
7. Conduct rounds to assess and coordinate care for high-risk patients, collaborating with care management teams.
8. Work with clinical teams, providers, and consultants on complex cases and appeals.
9. Participate in provider network development and market expansion.
10. Support physician education on clinical issues and policies.
11. Identify utilization review studies and evaluate trends and provider practices.
12. Identify clinical quality improvement opportunities to enhance care and reduce costs.
13. Facilitate implementation of utilization and quality recommendations with providers.
14. Review claims for complex or unusual services to determine medical necessity and payment appropriateness.
15. Develop alliances with providers through medical management programs.
16. Represent the business unit at public forums and committees as needed.
17. May work weekends and holidays to support operations.

Qualifications:

Medical Doctor or Doctor of Osteopathy with active practice. Utilization Management experience and knowledge of accreditation standards preferred. Coursework in health administration, financing, insurance, or personnel management is advantageous. Experience with diverse populations preferred.

Licenses/Certifications:

Board certification in a recognized medical specialty. Current unrestricted California MD or DO license.

Compensation & Benefits:

Salary range: $231,900 - $440,500 per year. Benefits include health insurance, 401K, stock plans, tuition reimbursement, paid time off, and flexible work arrangements. Actual pay depends on experience and qualifications.

Additional Information:

Centene is an equal opportunity employer committed to diversity. All qualified applicants will be considered without regard to protected characteristics. Candidates with arrest or conviction records will be considered per applicable laws.

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