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Inpatient Medicare 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 focus on enhancing care quality and cost-effectiveness. Possesses strong leadership skills to collaborate with clinical teams and develop educational programs for providers.
Highest-signal resume keywords
Medical Doctor (MD) or Doctor of Osteopathy (DO)Board Certification in a Medical SpecialtyUtilization Management ExperienceQuality Improvement KnowledgeExperience with Culturally Diverse Populations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewQuality AssuranceMedical ReviewCost ContainmentClinical Quality ImprovementPerformance Improvement InitiativesProvider Network DevelopmentClinical Education DevelopmentAdverse Utilization Trend EvaluationHealthcare Quality Improvement
Soft Skills
CollaborationLeadershipCommunicationProblem-SolvingInterpersonal Skills
Certifications & Qualifications
Board Certification in a Medical SpecialtyCurrent State License as MD or DO
Industry Keywords
Quality Accreditation StandardsHealth AdministrationHealth FinancingInsurance ManagementCulturally Diverse Population Care
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 utilization review, quality assurance, and medical review of complex, controversial, or experimental services
- Support performance improvement initiatives for capitated providers
- Help establish goals and policies to improve quality and cost-effectiveness of care
- Provide medical expertise for quality improvement and utilization management programs
- Assist with physician committee structure, processes, and membership
- Conduct regular rounds for high-risk patients and coordinate care with care management teams
- Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on complex cases and appeals
- Participate in provider network development and new market expansion
- Develop and implement physician education on clinical issues and policies
- Identify utilization review studies and evaluate adverse utilization trends, 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 complex, controversial, unusual, or new-service claims for medical necessity and appropriate payment
- Develop provider-community alliances through medical management programs
- Represent the business unit before local and national publics as needed
- Represent the business unit at state and ad hoc committees
Requirements
What you’ll need- Medical Doctor or Doctor of Osteopathy
- Actively practices medicine
- 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
- Utilization Management experience and knowledge of quality accreditation standards preferred
- Certification in Internal or Family Medicine 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 in support of business operations, 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