Medical Director

Centene Corporation Las Vegas , NV 89134

Posted 9 months ago

Position Purpose: 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. 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. Oversees the activities of physician advisors.

Utilizes the services of 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. As needed, 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

Education/Experience: Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine). The candidate must be an actively practicing physician.

Previous experience within a managed care organization is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred. Experience treating or managing care for a culturally diverse population preferred.

License/Certifications: Board Certification through American Board Medical Specialties. Current state medical license without restrictions.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.



icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Hospital Sales Director Sunrise Hospital And Medical Center

HCA

Posted 2 weeks ago

VIEW JOBS 11/26/2019 12:00:00 AM 2020-02-24T00:00 JOB TITLE: Director of Physician and Provider Relations (PPR), Generalist (Hospital or Market) GENERAL SUMMARY OF DUTIES: The Director of Physician and Provider Relations, Generalist is responsible for developing and retaining customer relationships to drive growth for key hospital services. The Generalist works as an extension of hospital leadership and operations, focusing on key internal and external customers to grow hospital volumes. These customers include: physicians and surgeons, CEOs of outreach hospitals, EMS leadership, free standing ER/urgent care leadership and staff, advanced practice providers, surgical leadership, and physician office staff. The generalist represents a key leadership role in the hospital and is proficient in working within an integrated sales organization. SUPERVISOR: Reports directly to Division Vice President of Physician and Provider Relations. Matrixed reporting relationship to hospital CEO. SUPERVISES: Not applicable. DUTIES INCLUDE BUT ARE NOT LIMITED TO: * Develops and executes strategic plans to grow hospital volumes, including inpatient admissions, outpatient services and surgical volumes. * Engages with physicians and surgeons in the OR, understands basic OR protocols and procedures. * Evaluates market data and financial information for facility service lines in collaboration with leadership, to identify priorities, create data-driven customer target lists, call cycles, and develop sales plans with measurable results. * Actively prospects for new business and growth in hospital environment. * Identifies barriers and communicates to leadership using CRM system. Is responsible for Issue Resolution processes and works to implement solutions and completes follow-up meetings to gain or retain business. * Using internal and external data and resources, develops an understanding of service line attributes, trends and opportunities to develop a clear service line strategy and growth plan with measurable results. * Builds data-driven business cases for strategic growth proposals such as physician recruitment/employment, service line development, equipment purchases or foot-print expansion and proactively presents to facility leadership. * Develops understanding of customer's business and challenges, and uses that understanding to develop sales plan and customer focused solutions. * Identifies critical activities and tasks, effectively allocates time to consistently meet or exceed productivity expectations; develops and maintains a call cycle and routing plan. * Executes sales strategies and monitors effectiveness of sales plan and modifies strategies and activities as necessary based on measurable results. Educates customers on services offered by facility and effectively conveys benefits of the business relationship. * Completes consultative sales meetings with customers to gain a thorough understanding of customer needs, business and challenges, and uses that understanding to develop a sales plan and customer-focused solutions to drive facility growth. Consistently uses CRM system to track activities. * Prepares and presents sales reports as required by leadership to identify trends, additional business opportunities and obstacles to business growth. * Participates in annual strategic business planning and leads medical staff development/succession planning. * Executes strategic physician engagement projects, including but not limited to the Physician Engagement Study, Medical Staff Planning, and Physician Referral Panel programs. EDUCATION * Bachelor's degree from an accredited college or university preferred. * Master's degree in Healthcare, Healthcare Administration or Business a plus. EXPERIENCE * Seasoned "consultative or service-oriented" sales experience required. 5 years of progressive healthcare sales experience in hospital, pharmaceutical or device sales; comparable experience may be considered. HCA Las Vegas NV

Medical Director

Centene Corporation