Medical Director, Appeals

🔥 42 minutes ago

🌵 Arizona, New Mexico, +3 more states – Remote

🌵 Arizona – Remote 🌶️ New Mexico – Remote 🏰 Missouri – Remote ⛷️ Utah – Remote ☕ Washington – Remote

💵 $236.5k - $449.3k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

Healthcare Insurance • Non-profit • Social Impact

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Assist the Chief Medical Director to direct and coordinate medical management, quality improvement, and credentialing functions • Provide medical leadership for utilization management, cost containment, and medical quality improvement activities • Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services • Support effective implementation of performance improvement initiatives for capitated providers • Assist Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care • Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements • Assist the Chief Medical Director in the functioning of physician committees • Collaborate effectively with clinical teams, network providers, appeals team, and consultants for reviewing complex cases • Participate in provider network development and new market expansion • Assist in the development and implementation of physician education regarding clinical issues and policies • Identify utilization review studies and evaluate adverse trends in utilization of medical services • Interface with physicians and other providers to facilitate implementation of recommendations for improving utilization and health care quality • Review claims involving complex, controversial, or unusual services to determine medical necessity and appropriate payment • Develop alliances with the provider community through medical management programs • Represent the business unit before various publics both locally and nationally on medical philosophy and policies.

🎯 Requirements

• Medical Doctor or Doctor of Osteopathy • Utilization Management experience and knowledge of quality accreditation standards preferred • Actively practices medicine • Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous • Experience treating or managing care for a culturally diverse population preferred • Active 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 specialty preferred • Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

🏖️ Benefits

• competitive pay • health insurance • 401K and stock purchase plans • tuition reimbursement • paid time off plus holidays • flexible approach to work with remote, hybrid, field or office work schedules