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Medical Director – UM Optimization
Centene Corporation. Assist the Chief Medical Officer to direct and coordinate 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, Utilization Management, and Quality Improvement, with a strong focus on strategic process improvement and collaboration with clinical teams. Holds a Medical Doctor or Doctor of Osteopathy degree, along with board certification in Psychiatry and relevant experience in managed care and quality accreditation standards.
Highest-signal resume keywords
Medical Doctor Or Doctor Of OsteopathyBoard Certification In PsychiatryUtilization Management ExperiencePayer Managed Care ExperienceQuality Improvement Expertise
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 ManagementUtilization ManagementQuality ImprovementData AnalysisMedical Review ActivitiesPerformance Improvement InitiativesClinical Quality ImprovementHealthcare QualityCost ContainmentStrategic Process Improvement
Soft Skills
CollaborationLeadershipCommunicationProblem-SolvingCultural Competence
Certifications & Qualifications
Board Certification In A Medical SpecialtyCurrent State License As A MD Or DO
Industry Keywords
Quality Accreditation StandardsHealth AdministrationHealth FinancingInsurancePersonnel ManagementCulturally Diverse PopulationProvider Network DevelopmentMedical Necessity AppealsAdverse Utilization TrendsProvider Community Alliances
About the role
Key responsibilities & impact- Assist the Chief Medical Officer to direct and coordinate medical management, quality improvement, and credentialing functions
- Provide medical leadership for Utilization Management, cost containment, and medical quality improvement activities
- Evaluate completed work, analyze data, and make strategic process improvement decisions
- Perform medical review activities for utilization review, quality assurance, and complex, controversial, or experimental medical services
- Support performance improvement initiatives for capitated providers
- Assist in 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 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, adverse utilization trends, unusual provider practice patterns, and benefit/payment adequacy issues
- Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice
- 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 local and national publics, state committees, and ad hoc committees as needed
Requirements
What you’ll need- Medical Doctor or Doctor of Osteopathy
- Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs
- 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
- Certification in Psychiatry specialty is required
- Actively practices medicine
- Utilization Management experience and knowledge of quality accreditation standards preferred
- Payer/Managed Care experience heavily preferred
- Coursework 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 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