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Medical Director, Pharmacy
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 cost containment and regulatory compliance. Proven ability to collaborate with clinical teams and develop provider-community alliances to enhance healthcare quality and effectiveness.
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 DeterminationPerformance Improvement InitiativesClinical Quality ImprovementCost Containment StrategiesComplex Case CollaborationProvider Network DevelopmentAdverse Utilization Trend Evaluation
Soft Skills
LeadershipCollaborationCommunicationProblem-SolvingEducation and Training
Certifications & Qualifications
Board Certification in 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 medical reviews for utilization review, quality assurance, and complex, controversial, or experimental medical services
- Support performance improvement initiatives for capitated providers
- Assist in establishing 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
- Assist with physician committee 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 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 local and national publics on medical philosophy, policies, and related issues as needed
- Represent the business unit at state and ad hoc committees
- Work weekends and holidays as needed to support business operations
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