Medical Director

Centene Corporation

Medical Director assisting the Chief Medical Director in directing medical management and quality improvement for the Pennsylvania Health Plan. Collaborating with health professionals to optimize patient care and quality standards.

Posted 5/22/2026full-timeRemote • Pennsylvania • 🇺🇸 United StatesLead💰 $225,700 - $428,900 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, ensuring timely and quality decision making
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 in accordance with regulatory, state, corporate, and accreditation requirements
Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership
Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes
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, unusual provider practice patterns, and adequacy of benefit/payment components
Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care
Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality
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
Represents the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues
Represents the business unit at appropriate state committees and other ad hoc committees
May be required to work weekends and holidays in support of business operations, as needed

Requirements

What you’ll need

MD or DO without restrictions
Must be licensed in Pennsylvania
Board Certified Physician
Utilization Management experience and knowledge of quality accreditation standards preferred
Actively practices medicine or has been an actively practicing physician within the last 5 years
Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous
Experience treating or managing care for a culturally diverse population preferred.

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 improvementcost containmentclinical quality improvementmedical necessity determinationprovider network developmentclaims reviewhealth administrationhealth financing

Soft Skills

leadershipcollaborationcommunicationdecision makingorganizational skillsproblem-solvinginterpersonal skillsstrategic planningteam coordinationeducational development

Certifications

MDDOBoard Certified Physicianlicensed in Pennsylvania