Position Purpose: 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 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. Oversees the activities of physician advisors. Utilizes the services of 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. As needed, may represent 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
For NH Substance Use Disorder Physician:
Provides clinical oversight and guidance for the MCO on Substance Use Disorder issues, including issues such as the use of ASAM or other evidence-based assessments and treatment protocols, the use of MAT, engagement with PRSS, and discharge planning for members who visit an ED or are hospitalized for an overdose.
Consults on MCO clinical policy related to Substance Use Disorders and the cases of individual members for the MCM program on a routine basis.
Education/Experience: Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine). The candidate must be an actively practicing physician. Previous experience within a managed care organization is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred. Experience treating or managing care for a culturally diverse population preferred.
License/Certifications: Board Certification through American Board Medical Specialties. Current state medical license without restrictions.
For Behavioral Health only - Board certification by the American Board of Psychiatry and Neurology. Current state medical license without restrictions.
For Buckeye Community Health Plan, Board certification in general psychiatry or child psychiatry. 5+ years of experience working in behavioral health managed care or behavioral health clinical settings, with at least 2 years in a clinical setting. Certification in addiction medicine or in the sub-specialty of addiction psychiatry preferred.
For NH Substance Abuse Disorder Physician Only: Board Certification through American Board Medical Specialties. Certification in addiction medicine or in the sub-specialty of addiction psychiatry. Current state medical license without restrictions.
For Nevada only: Board Eligible physician with current state medical license without restrictions. Physician must obtain Board Certification in specialty within reasonable time frame.
For Oklahoma Specialty Children's Plan only: Board certified and currently licensed in the state of Oklahoma as a child psychiatrist.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.See More
Valid through: 9/23/2021