Senior Medical Director – Appeals, National Physical Health UM Team
Centene Corporation
full-time
Posted on:
Location Type: Remote
Location: Remote • Montana • 🇺🇸 United States
Visit company websiteSalary
💰 $231,900 - $440,500 per year
Job Level
Senior
About the role
- Lead a team of medical directors and supervise MD’s responsible for utilization management and appeals functions
- Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit
- Provide medical leadership for all utilization management (appeals), pharmacy, case management, disease management, cost containment, and medical quality improvement activities
- Develop and have oversight of training and expertise for Medicare appeals reviews, ALJ hearings
- Provide medical expertise in the operation of approved quality improvement and utilization management programs
- Assist in the development and implementation of physician education with respect to clinical issues and policies
- Review claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
- May develop alliances with the provider community through the development and implementation of the medical management programs.
Requirements
- Medical Doctor or Doctor of Osteopathy
- 7+ years of clinical experience in the practice of medicine
- Advanced degree in health care management, informatics preferred but not required
- Management experience, 5 years or more of leading large physician teams in a matrixed environment, preferred
- Deep knowledge of Medicare policies and procedures (Manuals, NCD’s, LCD’s, final rules, STARS metrics) and previous experience leading Medicare Appeals, IRE and ALJ hearings, STARS metrics
- Previous experience with ensuring high quality medical director training to review Medicare UM and appeals, Clinical review quality oversight and management
- Utilization Management experience and knowledge of quality accreditation standards preferred
- Experience analyzing and working with complex data sets and knowledge of population health preferred
- Experience treating or managing care for a culturally diverse population preferred
- 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.
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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
utilization managementMedicare appealsclinical reviewdata analysispopulation healthmedical quality improvementcost containmentcase managementpharmacy managementphysician education
Soft skills
leadershipteam managementcommunicationcollaborationtraining and developmentstrategic planningproblem-solvinginterpersonal skillsorganizational skillscultural competency
Certifications
Board certificationcurrent state license as MDcurrent state license as DO