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Behavioral Health Medical Director – UM Optimization
Centene Corporation. Assist the Chief Medical Officer to direct and coordinate 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 Utilization Management, quality improvement, and medical leadership, with a strong focus on strategic planning and regulatory compliance. Proven ability to analyze data, evaluate clinical practices, and implement process improvements to enhance healthcare quality and cost-effectiveness.
Highest-signal resume keywords
Medical Doctor (MD) or Doctor of Osteopathy (DO)Board Certification in PsychiatryUtilization Management ExperienceCurrent State Medical LicensePayer/Managed Care Experience
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 ReviewData AnalysisMedical Necessity DeterminationPerformance Improvement InitiativesClinical Quality ImprovementStrategic PlanningCredentialing FunctionsProvider Network Development
Soft Skills
CollaborationLeadershipCommunicationDecision-MakingInterpersonal Skills
Certifications & Qualifications
Board Certification by the American Board of Psychiatry and NeurologyCertification in Psychiatry Specialty
Industry Keywords
Quality Accreditation StandardsHealth AdministrationHealth FinancingInsuranceCulturally Diverse Population
About the role
Key responsibilities & impact- Assist the Chief Medical Officer to direct and coordinate medical management, quality improvement, and credentialing functions
- Provide medical leadership for Utilization Management, cost containment, and medical quality improvement activities
- Lead strategic planning and optimization of Utilization Management processes
- Evaluate completed work, analyze data, and make decisions on strategic process improvements
- Perform medical reviews for utilization review, quality assurance, and complex, controversial, or experimental services
- Support performance improvement initiatives for capitated providers
- Assist in establishing 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 committee structure, processes, and membership
- Conduct regular rounds for high-risk patients and coordinate 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 and clinical quality improvement studies
- Evaluate adverse utilization trends, unusual provider practice patterns, and benefit/payment adequacy
- Interface with physicians and providers to implement recommendations improving utilization and healthcare quality
- Review complex claims to determine medical necessity and appropriate payment
- Develop provider-community alliances through medical management programs
- Represent the business unit before local and national publics and at state or ad hoc committees as needed
Requirements
What you’ll need- 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
- Certification in Psychiatry specialty is required
- Board certification by the American Board of Psychiatry and Neurology
- Current state medical license as an MD or DO without restrictions, limitations, or sanctions from government programs
- Utilization Management experience and knowledge of quality accreditation standards preferred
- Actively practices medicine preferred, but not required
- Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management advantageous
- Experience treating or managing care for a culturally diverse population preferred
- Payer/Managed Care experience heavily preferred
- May be required to work weekends and holidays as needed
Benefits
Comp & perks- Competitive pay
- Health insurance
- 401K
- 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