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Medical Director, Appeals
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 regulatory compliance and cost-effectiveness in healthcare delivery. Proven ability to collaborate with clinical teams and provide medical leadership in complex cases and performance improvement initiatives.
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
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 ReviewMedical Necessity EvaluationPerformance Improvement InitiativesClinical Quality Improvement StudiesProvider Network DevelopmentCost Containment StrategiesAdverse Utilization Trend EvaluationHealthcare Quality Improvement
Soft Skills
CollaborationLeadershipCommunicationProblem-SolvingEducation and Training
Certifications & Qualifications
Board Certification in Medical SpecialtyCurrent State License as MD or DO
Industry Keywords
Quality AssuranceAccreditation RequirementsCulturally Diverse PopulationHealth 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 goals and policies to improve quality and cost-effectiveness of care and service
- Provide medical expertise for quality improvement and utilization management programs meeting 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 regarding 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, 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 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- 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
- Competitive pay