Medical Director, Appeals

Centene Corporation

. Assist the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions .

Posted 10/14/2026full-timeRemote • United StatesLead💰 $215,000 - $408,500 per yearWebsite

Core Competencies

Role fit

Core 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 providers to enhance care quality and address complex medical cases.

Highest-signal resume keywords

Medical Doctor (MD) or Doctor of Osteopathy (DO)Board Certification in Medical SpecialtyUtilization Management ExperienceQuality Accreditation Standards KnowledgeExperience with Culturally Diverse Populations

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical ManagementQuality ImprovementUtilization ReviewMedical Necessity DeterminationPerformance Improvement InitiativesClinical Quality ImprovementProvider Network DevelopmentCost Containment StrategiesComplex Case ManagementHealthcare Policy Implementation

Soft Skills

CollaborationLeadershipCommunicationProblem-SolvingEducation and Training

Certifications & Qualifications

Board Certification in Medical SpecialtyCurrent State License as MD or DO

Industry Keywords

Quality AssuranceAccreditation RequirementsHealth AdministrationHealth FinancingInsurance ManagementCulturally Diverse Population CareCapitated ProvidersPublic Health RepresentationAd Hoc CommitteesPhysician Committee Structure

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 reviews for utilization review, quality assurance, and complex, controversial, or experimental medical services
Support performance improvement initiatives for capitated providers
Assist with goals and policies to improve quality and cost-effectiveness of care and service
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 to assess and coordinate care for high-risk patients
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
Support 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 and improve quality and cost of care
Interface with physicians and providers to implement recommendations improving utilization and healthcare quality
Review complex, controversial, unusual, or new-service claims to determine medical necessity and appropriate payment
Develop provider-community alliances through medical management programs
Represent the business unit before public audiences, state committees, and ad hoc committees as needed

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 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