Sunshine Health
Overview
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits and flexible workplace options. Base pay
Base pay range: $231,900.00/yr - $440,500.00/yr Responsibilities
Provide medical leadership for utilization management, cost containment, and medical quality improvement activities. Perform medical review activities related to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services; ensure timely and quality decision making. Support the implementation of performance improvement initiatives for capitated providers. Assist the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assist the Chief Medical Director with the functioning of 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. Collaborate with clinical teams, network providers, appeals team, and medical/pharmacy consultants for reviewing complex cases and medical necessity appeals. Participate in provider network development and new market expansion as appropriate. Contribute to physician education on clinical issues and policies. Identify utilization review studies and evaluate adverse trends in utilization, unusual provider practice patterns, and adequacy of benefit/payment components. Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice and improve quality and cost of care. Interface with physicians and other providers to facilitate implementation of recommendations that improve utilization and health care quality. Review claims involving complex or new services to determine medical necessity and appropriate payment. Develop alliances with the provider community through medical management program initiatives. Represent the business unit before various publics locally and nationally on medical philosophy, policies, and related issues as needed. Represent 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. Education / Experience
Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred. Must reside in Florida. Licenses / Certifications
Board certification by the American Board of Psychiatry and Neurology. Current Florida state medical license without restrictions. Pay and Benefits
Pay range: $231,900.00 - $440,500.00 per year Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and flexible work options (remote, hybrid, field, or office). Actual pay will be adjusted based on skills, experience, education, and status (full-time or part-time). Total compensation may include additional incentive forms. Benefits subject to program eligibility. Equal Opportunity
Centene is an equal opportunity employer committed to diversity. 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 law. Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws. Senioriy / Employment Type / Function / Industries
Seniority level: Not Applicable Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care, Insurance Note
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You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits and flexible workplace options. Base pay
Base pay range: $231,900.00/yr - $440,500.00/yr Responsibilities
Provide medical leadership for utilization management, cost containment, and medical quality improvement activities. Perform medical review activities related to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services; ensure timely and quality decision making. Support the implementation of performance improvement initiatives for capitated providers. Assist the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assist the Chief Medical Director with the functioning of 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. Collaborate with clinical teams, network providers, appeals team, and medical/pharmacy consultants for reviewing complex cases and medical necessity appeals. Participate in provider network development and new market expansion as appropriate. Contribute to physician education on clinical issues and policies. Identify utilization review studies and evaluate adverse trends in utilization, unusual provider practice patterns, and adequacy of benefit/payment components. Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice and improve quality and cost of care. Interface with physicians and other providers to facilitate implementation of recommendations that improve utilization and health care quality. Review claims involving complex or new services to determine medical necessity and appropriate payment. Develop alliances with the provider community through medical management program initiatives. Represent the business unit before various publics locally and nationally on medical philosophy, policies, and related issues as needed. Represent 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. Education / Experience
Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred. Must reside in Florida. Licenses / Certifications
Board certification by the American Board of Psychiatry and Neurology. Current Florida state medical license without restrictions. Pay and Benefits
Pay range: $231,900.00 - $440,500.00 per year Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and flexible work options (remote, hybrid, field, or office). Actual pay will be adjusted based on skills, experience, education, and status (full-time or part-time). Total compensation may include additional incentive forms. Benefits subject to program eligibility. Equal Opportunity
Centene is an equal opportunity employer committed to diversity. 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 law. Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws. Senioriy / Employment Type / Function / Industries
Seniority level: Not Applicable Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care, Insurance Note
Referrals increase your chances of interviewing at Sunshine Health. Get notified about new Medical Director jobs in Florida, United States.
#J-18808-Ljbffr