Arizona Complete Health
Position Purpose
Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement, and credentialing functions for the business unit.
Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
Perform medical review activities for utilization review, quality assurance, and complex or experimental medical services, ensuring timely and quality decision‑making.
Support effective 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 for members.
Provide medical expertise in operating approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assist the Chief Medical Director in the functioning of physician committees, including 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 effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participate in provider network development and new market expansion as appropriate.
Assist in developing and implementing physician education related to clinical issues and policies.
Identify utilization review studies and evaluate adverse trends in utilization of medical services, 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 healthcare quality.
Review claims involving complex, controversial, or new services to determine medical necessity and appropriate payment.
Develop alliances with the provider community through implementation of medical management programs.
Represent the business unit before various publics locally and nationally on medical philosophy, policies, and related issues.
Represent the business unit at appropriate state committees and other ad‑hoc committees.
Be available to work weekends and holidays in support of business operations, as needed.
Consult on MCO clinical policy related to Substance Use Disorders and individual member cases for the MCM program on a routine basis.
Perform other duties as assigned.
Comply with all policies and standards.
Education/Experience Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Coursework 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 in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services. Current Arizona state license as an MD or DO with no restrictions, limitations, or sanctions from government programs.
Pay Range $221,300.00 – $420,500.00 per year.
Benefits Centene offers a comprehensive benefits package including competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office schedules. Total compensation may also include additional forms of incentives and may be subject to program eligibility.
EEO Statement Centene is an equal opportunity employer that is committed to diversity, values different perspectives, and considers all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status or other protected characteristics. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.
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Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
Perform medical review activities for utilization review, quality assurance, and complex or experimental medical services, ensuring timely and quality decision‑making.
Support effective 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 for members.
Provide medical expertise in operating approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assist the Chief Medical Director in the functioning of physician committees, including 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 effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participate in provider network development and new market expansion as appropriate.
Assist in developing and implementing physician education related to clinical issues and policies.
Identify utilization review studies and evaluate adverse trends in utilization of medical services, 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 healthcare quality.
Review claims involving complex, controversial, or new services to determine medical necessity and appropriate payment.
Develop alliances with the provider community through implementation of medical management programs.
Represent the business unit before various publics locally and nationally on medical philosophy, policies, and related issues.
Represent the business unit at appropriate state committees and other ad‑hoc committees.
Be available to work weekends and holidays in support of business operations, as needed.
Consult on MCO clinical policy related to Substance Use Disorders and individual member cases for the MCM program on a routine basis.
Perform other duties as assigned.
Comply with all policies and standards.
Education/Experience Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Coursework 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 in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services. Current Arizona state license as an MD or DO with no restrictions, limitations, or sanctions from government programs.
Pay Range $221,300.00 – $420,500.00 per year.
Benefits Centene offers a comprehensive benefits package including competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office schedules. Total compensation may also include additional forms of incentives and may be subject to program eligibility.
EEO Statement Centene is an equal opportunity employer that is committed to diversity, values different perspectives, and considers all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status or other protected characteristics. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.
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