Centene Corporation is a Fortune 500, mission-driven healthcare leader committed to transforming the health of the communities we service, one person at a time.
Medical Director
Location
South Carolina
Posted
45 days ago
Salary
$225.7K - $428.9K / year
Seniority
Lead
Job Description
Medical Director
Centene Corporation
• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. • Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. • Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. • Supports effective implementation of performance improvement initiatives for capitated providers. • Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. • Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. • Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. • Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. • Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. • Participates in provider network development and new market expansion as appropriate. • Assists in the development and implementation of physician education with respect to clinical issues and policies. • Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. • Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. • Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. • Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. • Develops alliances with the provider community through the development and implementation of the medical management programs. • May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. • Represents the business unit at appropriate state committees and other ad hoc committees. • May be required to work weekends and holidays in support of business operations, as needed.
Job Requirements
- MD or DO without restrictions
- Must be licensed in South Carolina
- Residency in South Carolina
- Board Certified Physician
- Utilization Management experience and knowledge of quality accreditation standards preferred
- Actively practices medicine or has been an actively practicing physician within the last 5 years
- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous
- Experience treating or managing care for a culturally diverse population preferred
- 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 South Carolina state license as a MD or DO without restrictions, limitations, or sanctions from government programs.
Benefits
- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
Related Guides
Related Categories
Related Job Pages
More Medical Director Jobs
Medical Director, Men's Health
AmnealAmneal is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by applicable federal, state, or local laws. If you require a reasonable accommodation to complete the application process or to participate in any part of the hiring process, please contact us at accommodations@amneal.com. Requests will be handled confidentially and in accordance with applicable laws.
Role Description The Medical Science Director will serve as an internal scientific expert supporting products in an assigned therapeutic area. This role has responsibility for responding to Medical Information Requests, clinical support for the field sales teams, clinical support for customers, and the product development strategy. - Provide clinical and scientific expertise in the assigned therapeutic area to support internal teams, healthcare professionals (HCPs), and stakeholders. - Respond to medical information requests from healthcare providers, external partners, and internal departments with accurate, balanced, and timely information. - Lead and participate in advisory boards, KOL engagements, and scientific exchange to gather and provide insights for product development and medical strategy. - Collaborate with Clinical Operations to provide medical oversight and support for clinical trials including investigator-initiated studies. - Work closely with cross-functional teams (R&D, clinical development, regulatory affairs, commercial) to ensure medical insights are integrated into company strategies and product life cycle management. - Develop and deliver high-quality scientific presentations and materials for both internal and external audiences, including HCPs and key opinion leaders (KOLs). - Ensure that all medical communication, promotional material reviews, and activities comply with regulatory requirements, company policies, and ethical standards. - Provide ongoing medical and scientific training to internal teams, including sales and medical affairs, to ensure a deep understanding of oncology products and disease states. Company Description
Medical Director
Health Care Service CorporationEmpowering Whole Person Health With Compassion and Innovation
• responsible for assigned aspects of medical policies and programs • performs medical reviews • interacts with the provider communities for assigned areas
• Provide strategic and scientific medical leadership for immunology product(s). • Become a disease state and product expert, providing feedback and insights to medical affairs deliverables, and cross-functional partners, including the design and implementation of Medical Affairs plans • Work closely with the medical field team to develop/enhance KOL and key institution engagement plans and participate in KOL engagement and development, establishing Sobi Inc as a scientific partner of choice. • Help plan and execute advisory boards to obtain advice. • Create a medical education strategy and drive tactics to increase product and disease state education (webinars, medical roundtables, symposium, congress presence, CME strategy) • Partner with the field medical team to identify key resource needs and to collaborate on developing field materials and tactics. • Additionally, partner with the team to establish a medical training plan and provide training/education to cross-functional partners. • Develop US immunology product(s) evidence generation strategy to address stakeholder (HCPs, payers, and patients) needs (including product differentiation, health outcomes), collaborating with HEOR and global partners. • Oversee any medical affairs-led research initiatives, including US Phase IV clinical programs, post hoc analyses, and natural history studies, to address US needs. • Additionally, the Senior Medical Director will be a key contributor to the global life cycle management-led activities, including programs for future indications, cytokine testing, Investigator-Initiated Study strategy, and overall input into the creation and execution of product evidence generation plans • Oversee the US products publication strategy and execution, as well as contribute to the global publication plan and publications. • Partner with scientific communications to ensure timely dissemination of key scientific data and its incorporation into field materials and other educational resources. • Design and implement a medical advisory plan, collate medical insights, partner with the field team, and share them internally. • Analyze insights for adjustment to strategy and tactics • Develop and foster strong collaborative relationships with internal partners, including Regulatory Affairs, Clinical Operations, Market Access, Medical Information, Pharmacovigilance, Sales and Marketing, Global product leadership, Global medical affairs, and clinical development, providing strategic medical insight and product/disease-state expertise to meet business objectives. • Support the market access team as needed with medical expertise and in discussions/presentations to payers • Collaborate closely with global medical and clinical colleagues, ensuring US perspective and insights are incorporated into global initiatives • Interact with Key Opinion Leaders, Regulatory Authorities, Patient advocacy groups, and other external agencies in support of our products/ therapeutic areas of interest to advance company objectives to improve patient outcomes • Lead, or help lead, US product medical activities, including the US brand medical team.
Medical Director, Commercial
Excellus BlueCross BlueShieldUPSTARS – продуктова IT-компанія, з якою злітають і люди, і бренди. Наш основний фокус – технологічні рішення та B2B-послуги для міжнародних клієнтів.
Role Description The Medical Director participates in the broad array of activities of the Medical Services area including, but not limited to: - Medical and Pharmacy Utilization Management - Quality management - Member care management - Medical policy processes - Support for various lines of business The incumbent also provides input into the development of policies, programs, and strategic objectives that cover Medical Management Services through their required participation in various committees and when assigned to other committees or workgroups as requested by leadership. They also act as a liaison with local physicians and hospitals and keep abreast of practice patterns, issues, and concerns of their regional medical community, as well as support our Provider Relations team as requested. This position is occasionally required to work evenings during high volume periods and staff shortages, e.g. cross-coverage vacations. Qualifications - Minimum of seven (7) years of clinical practice experience after completion of all graduate medical education training, including residency and fellowship (when applicable). - Medical Degree: MD or DO from an accredited institution required. - Active board certification in Professional Medical Specialty. - Active unrestricted medical license to practice medicine in a state or territory of the United States. - The Physician is not the subject of any pending professional disciplinary action that could result in the impairment of their ability to practice medicine. - Knowledge of applicable state and federal laws, NCQA standards, and Utilization Management. - Demonstration of effective use of word processing, spreadsheet, email. - Strong interpersonal skills essential for communication to staff at all levels of the organization. - Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills. - Ability to work within changing business environment and balance patient advocacy with business needs. - Successful ability to assess complex issues, to determine and implement solutions, and resolve problems. - Demonstrated sensitivity to culturally diverse situations, participants, and customers/members. Requirements - Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes. - Identifies and develops opportunities for innovation to increase effectiveness and quality. - Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes. - Conduct clinical appeal case reviews and may require peer-to-peer discussions with providers regarding UM case review determinations. - Provides input into the utilization management program policies and procedures. - Assists in many aspects of frontline UM during high peak activity or staff outages. Benefits - Compensation Range: $202,000.00 - $303,000.00 - Participation in group health and/or dental insurance - Retirement plan - Wellness program - Paid time away from work - Paid holidays Physical Requirements - Ability to work prolonged periods sitting at a workstation and working on a computer. - Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time. - Typical office environment including fluorescent lighting. - Ability to work in a home office for continuous periods of time for business continuity. - Ability to travel across the Health Plan service region for meetings and/or trainings as needed. - Ability to lift, carry, push or pull 15 pounds or less. - Manual dexterity including fine finger motion required. - Repetitive motion required. - The ability to hear, understand and speak clearly while using a phone, with or without a headset.


