Join our dynamic Medical Management/Health Services team, where your expertise can make a significant impact on the lives of 28 million members. At Centene, we are a nationally diversified organization that prioritizes innovative benefits and offers a modern approach to workplace flexibility.

Position Overview:
We are seeking a motivated clinical professional to assist the Chief Medical Director in leading and coordinating our medical management, quality enhancement, and credentialing processes within the organization.

• Lead all medical management initiatives focusing on utilization review, cost minimization, and quality improvement in healthcare delivery.
• Conduct comprehensive medical review activities related to utilization assessment, quality assurance, and complex cases to ensure prompt and high-quality decisions.
• Drive performance improvement initiatives for capitated providers, fostering an environment of efficiency and excellence.
• Collaborate with the Chief Medical Director to set strategic goals and policies aimed at enhancing healthcare quality and cost-effectiveness for our members.
• Provide medical insights while adhering to regulatory, state, corporate, and accreditation standards for quality improvement and utilization management programs.
• Support the Chief Medical Director in the organization and effectiveness of physician committees, ensuring robust processes and appropriate membership.
• Engage in regular assessments of high-risk patients, working closely with care management teams to optimize health outcomes.
• Collaborate with clinical teams, network providers, the appeals team, and medical/pharmacy consultants for reviewing complex medical cases and appeals for medical necessity.
• Participate in network development and the expansion into new markets when necessary.
• Aid in creating and implementing physician education programs related to clinical standards and policies.
• Conduct utilization review studies and assess trends concerning medical service usage, identifying unusual provider practices and evaluating the adequacy of benefits and payments.
• Initiate clinical quality improvement projects aimed at reducing unwarranted variations in care, ultimately enhancing both quality and cost-efficiency in healthcare.
• Connect with physicians and providers to promote the implementation of recommendations aimed at improving healthcare quality and utilization.
• Review cases involving complex, experimental, or controversial medical services to determine their necessity and appropriate payment.
• Establish collaborative relationships within the provider community by developing and executing medical management programs.
• Represent the business unit externally on medical philosophies, policies, and pertinent issues at both local and national levels.
• Attend and contribute to relevant state committees and ad hoc groups as required.
• Flexibility in working hours may be needed, including weekends and holidays, to support operational needs.

Qualifications:

• Medical Doctor (MD) or Doctor of Osteopathy (DO) required, with clinical practice experience.
• Expertise in Utilization Management and familiarity with quality accreditation standards is preferred.
• Course completion in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
• Experience working with culturally diverse populations is preferred.

Licensure/Certifications:

• Board certification by the American Board of Psychiatry and Neurology is essential.
• A current and unrestricted state medical license (MD or DO) is required, free from limitations or sanctions from governmental programs.

Compensation:
Salary range: $231,900.00 – $440,500.00 annually, determined by individual skills, experience, education, and applicable job factors.

Benefits:
Centene proudly offers a comprehensive benefits package including competitive compensation, health insurance, 401K plans, stock purchase options, tuition reimbursement, and generous paid time off, including holidays. Enjoy the flexibility of choosing between remote, hybrid, field, or in-office work arrangements.

Centene is an equal opportunity employer that celebrates diversity and is committed to creating an inclusive environment for all employees. We encourage qualified candidates from all backgrounds to apply, regardless of race, color, religion, gender, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics under the law.

Qualified candidates with records of arrests or convictions will be considered in compliance with the LA County Ordinance and the California Fair Chance Act.