Medical Director, Appeals

Centene Corporation

Medical Director leading medical management and quality improvement initiatives for a diverse healthcare organization. Collaborating with clinical teams and regulatory bodies to optimize healthcare delivery.

Posted 5/8/2026full-timeRemote • Arizona, Montana, New Mexico, Ohio, Utah • 🇺🇸 United StatesLead💰 $236,500 - $449,300 per yearWebsite

About the role

Key responsibilities & impact

Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
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
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
Assists the Chief Medical Director in the functioning of the physician committees
Conduct regular rounds to assess and coordinate care for high-risk patients
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
Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice
Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers
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
May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues
May be required to work weekends and holidays in support of business operations, as needed

Requirements

What you’ll need

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 and/or Family Medicine specialty, preferred
Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Benefits

Comp & perks

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

utilization managementmedical reviewquality assurancecost containmentperformance improvementclinical quality improvementclaims reviewmedical necessity determinationprovider network developmentphysician education

Soft Skills

medical leadershipcollaborationcommunicationcoordinationgoal settingpolicy developmentassessmentproblem-solvinginterpersonal skillscultural competency

Certifications

Medical Doctor (MD)Doctor of Osteopathy (DO)Board certification in medical specialtyCertification in Internal MedicineCertification in Family Medicine