Medical Director, Appeals

Centene Corporation

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

Posted 10/5/2026full-timeRemote • United StatesLead💰 $215,000 - $408,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical management, quality improvement, and utilization management, with a focus on cost containment and enhancing healthcare quality. Possesses strong leadership skills to collaborate effectively with clinical teams and support performance improvement initiatives.

Highest-signal resume keywords

Medical Doctor Or Doctor Of OsteopathyBoard Certification In A Medical SpecialtyUtilization Management ExperienceQuality Improvement ProgramsExperience With Culturally Diverse Populations

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical ManagementQuality ImprovementUtilization ReviewComplex Claims ReviewHealthcare Quality Assessment

Soft Skills

CollaborationLeadershipCommunication

Certifications & Qualifications

Board CertificationCurrent State License As MD Or DO

Industry Keywords

Quality Accreditation StandardsCapitated ProvidersProvider Network DevelopmentHealth AdministrationHealth Financing

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 involving utilization review, quality assurance, and complex, controversial, experimental, unusual, or new medical services
Conduct regular rounds to assess and coordinate care for high-risk patients
Collaborate with care management teams, clinical teams, network providers, appeals teams, and medical and pharmacy consultants
Support performance improvement initiatives for capitated providers
Assist with planning goals and policies to improve quality and cost-effectiveness of care
Provide medical expertise for quality improvement and utilization management programs
Assist with physician committees, including structure, processes, and membership
Participate in provider network development and new market expansion
Support physician education on clinical issues and policies
Identify utilization review and clinical quality improvement studies and evaluate adverse utilization trends
Facilitate recommendations to providers to improve 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 public, state, 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

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