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Medical Director
Centene Corporation. Assist the CMO in directing and coordinating physician utilization management functions for health plan business units .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in utilization management and medical review, providing leadership in quality improvement initiatives while ensuring compliance with regulatory and accreditation standards. Possesses strong clinical judgment in reviewing complex medical cases and claims to determine medical necessity.
Highest-signal resume keywords
Board Certified PhysicianUtilization Management ExperienceCurrent Indiana State Medical LicenseExperience in Managed Care OrganizationPrimary Care Specialty
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 ReviewCase ReviewsQuality Improvement ProgramsClinical Quality Improvement StudiesClaims ReviewUtilization Review StudiesAdverse Utilization Trend EvaluationMedical Necessity DeterminationConsultant Services Utilization
Soft Skills
LeadershipCollaborationCommunication
Certifications & Qualifications
Board Certification Through American Board Medical Specialties
Industry Keywords
Health Plan Business UnitsCulturally Diverse PopulationHealth AdministrationHealth FinancingInsurancePersonnel ManagementMedicare Patients
About the role
Key responsibilities & impact- Assist the CMO in directing and coordinating physician utilization management functions for health plan business units
- Provide medical leadership for utilization management and medical review activities
- Review complex, controversial, experimental, unusual, or new medical services, including transplants
- Perform case reviews and appeals for all health plans
- Assist the CMO with planning goals and policies to improve quality and cost-effectiveness of care and services
- Provide medical expertise for quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements
- 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
- Review complex claims to determine medical necessity and appropriate payment
- Utilize consultant services when reviewing complex or controversial medical services
Requirements
What you’ll need- Must be a Board Certified Physician
- Medical Doctor or Doctor of Osteopathy
- Board certification through American Board Medical Specialties
- Current Indiana state medical license without restrictions
- Actively practicing physician
- Primary care specialty preferred: Internal Medicine, Med/Peds, Family Practice, Pediatrics or Emergency Medicine, or another specialty familiar with Medicare patients
- Utilization management experience ideal
- Previous experience within a managed care organization preferred
- Experience treating or managing care for a culturally diverse population preferred
- More than 1 state license preferred
- Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management preferred
- Availability for roughly 20 hours per week, with Thursdays/Fridays highest priority
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