Medical Director, Appeals

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🌵 Arizona, Colorado, +8 more states – Remote

🌵 Arizona – Remote ⛰️ Colorado – Remote 🦬 Montana – Remote 🎰 Nevada – Remote 🌶️ New Mexico – Remote 🌲 Oregon – Remote 🏰 Missouri – Remote ⛷️ Utah – Remote ☕ Washington – Remote 🦬 Wyoming – Remote

💵 $215k - $408.5k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

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 in directing and coordinating medical management, quality improvement, and credentialing functions • Provide medical leadership for utilization management, cost containment, and medical quality improvement activities • Perform medical review for utilization review, quality assurance, and complex, controversial, or experimental medical services • Support performance improvement initiatives for capitated providers • Assist with goals and policies to improve quality and cost-effectiveness of care and service • Provide medical expertise for quality improvement and utilization management programs meeting regulatory, state, corporate, and accreditation requirements • Assist with physician committees, including structure, processes, and membership • Conduct regular rounds for high-risk patients and collaborate with care management teams • Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on complex cases and medical necessity appeals • Participate in provider network development and new market expansion • Assist with physician education regarding clinical issues and policies • Identify utilization review and clinical quality improvement studies • Evaluate adverse utilization trends, unusual provider practice patterns, and benefit/payment adequacy • Interface with physicians and providers to implement recommendations improving utilization and healthcare quality • Review complex, controversial, unusual, or new-service claims for medical necessity and appropriate payment • Develop provider-community alliances through medical management programs • Represent the business unit before public audiences, state committees, and ad hoc committees as needed

🎯 Requirements

• Medical Doctor or Doctor of Osteopathy • Actively practices medicine • 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 • Utilization Management experience and knowledge of quality accreditation standards preferred • Certification in Internal or Family Medicine preferred • Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management advantageous • Experience treating or managing care for a culturally diverse population preferred • May be required to work weekends and holidays in support of business operations, as needed

🏖️ Benefits

• Health insurance • 401K • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Competitive pay