Superior HealthPlan
Remote Behavioral Medical Director - Texas
Superior HealthPlan, Granite Heights, Wisconsin, United States
Overview
Remote Behavioral Medical Director - Texas role at Superior HealthPlan. This position supports medical management, quality improvement, and credentialing functions for the business unit with a focus on utilization management and clinical leadership. Responsibilities
Provides medical leadership of all utilization management, cost containment, and medical quality improvement activities. Performs medical review activities related to utilization review, quality assurance, and review of complex, controversial, or experimental medical services to ensure timely and quality decision making. Supports effective implementation of performance improvement initiatives for capitated providers. Assists the 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 physician committees including committee structure, processes, and membership. Conducts regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. Collaborates with clinical teams, network providers, appeals team, and medical/pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in developing and implementing physician education related to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to reduce unwarranted variation in clinical practice and improve quality and cost of care. Interfaces with physicians and other providers to facilitate implementation of recommendations that improve utilization and health care quality. Reviews claims involving complex, controversial, unusual, or new services to determine medical necessity and appropriate payment. Develops alliances with the provider community through medical management program development and implementation. Represent the business unit before public forums on medical philosophy, policies, and related issues as needed. Represents the business unit at appropriate state committees and 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. License/Certifications
Board certification by the American Board of Psychiatry and Neurology. Current Texas state license as an MD or DO without restrictions, limitations, or sanctions from government programs. 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 a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual\'s skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Equal Opportunity
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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act. Job Details
Seniority level: Not Applicable Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care and Insurance Note: This description includes the key responsibilities, qualifications, and benefits associated with the Remote Behavioral Medical Director - Texas role. It excludes extraneous site prompts and unrelated content.
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Remote Behavioral Medical Director - Texas role at Superior HealthPlan. This position supports medical management, quality improvement, and credentialing functions for the business unit with a focus on utilization management and clinical leadership. Responsibilities
Provides medical leadership of all utilization management, cost containment, and medical quality improvement activities. Performs medical review activities related to utilization review, quality assurance, and review of complex, controversial, or experimental medical services to ensure timely and quality decision making. Supports effective implementation of performance improvement initiatives for capitated providers. Assists the 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 physician committees including committee structure, processes, and membership. Conducts regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. Collaborates with clinical teams, network providers, appeals team, and medical/pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in developing and implementing physician education related to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to reduce unwarranted variation in clinical practice and improve quality and cost of care. Interfaces with physicians and other providers to facilitate implementation of recommendations that improve utilization and health care quality. Reviews claims involving complex, controversial, unusual, or new services to determine medical necessity and appropriate payment. Develops alliances with the provider community through medical management program development and implementation. Represent the business unit before public forums on medical philosophy, policies, and related issues as needed. Represents the business unit at appropriate state committees and 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. License/Certifications
Board certification by the American Board of Psychiatry and Neurology. Current Texas state license as an MD or DO without restrictions, limitations, or sanctions from government programs. 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 a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual\'s skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Equal Opportunity
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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act. Job Details
Seniority level: Not Applicable Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care and Insurance Note: This description includes the key responsibilities, qualifications, and benefits associated with the Remote Behavioral Medical Director - Texas role. It excludes extraneous site prompts and unrelated content.
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