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Behavioral Health Medical Director
Centene Corporation. Assist the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical management, quality improvement, and utilization management, with a strong focus on regulatory compliance and cost-effectiveness in healthcare delivery. Proven ability to collaborate with clinical teams and manage complex cases while providing medical leadership and education.
Highest-signal resume keywords
Board Certified PsychiatristUtilization Management ExperienceMedical Doctor or Doctor of OsteopathyCurrent State License as MD or DOQuality Accreditation Standards Knowledge
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical ManagementQuality ImprovementUtilization ReviewClinical Quality ImprovementMedical Necessity DeterminationPerformance Improvement InitiativesClaims ReviewCulturally Diverse Population ManagementCost ContainmentProvider Network Development
Soft Skills
CollaborationLeadershipCommunicationEducationProblem-Solving
Certifications & Qualifications
Board Certification in Medical SpecialtyCurrent State License
Industry Keywords
Healthcare QualityAccreditation RequirementsHealth AdministrationHealth FinancingInsurance Management
About the role
Key responsibilities & impact- 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 planning goals and policies to improve quality and cost-effectiveness of care
- Provide medical expertise for quality improvement and utilization management programs in accordance with 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 on clinical issues and policies
- Identify utilization review studies and evaluate adverse utilization trends, unusual provider practice patterns, and benefit/payment adequacy
- Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice
- Interface with physicians and providers to implement recommendations improving utilization and healthcare quality
- Review claims involving complex, controversial, unusual, or new services to determine medical necessity and appropriate payment
- Develop provider-community alliances through medical management programs
- Represent the business unit before public audiences and at state or ad hoc committees as needed
Requirements
What you’ll need- Must be a Board Certified Psychiatrist
- Must be licensed in California, Oregon, Washington or Nevada
- Highly preferred to live in the Pacific Time Zone
- Medical Doctor or Doctor of Osteopathy
- 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
- Must actively practice medicine
- Utilization Management experience and knowledge of quality accreditation standards 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 as needed
Benefits
Comp & perks- Competitive pay
- Health insurance
- 401K plan
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation
- Equal opportunity employer committed to diversity