Remote Medical Director - Georgia

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 including a fresh perspective on workplace flexibility.
 

Position Purpose: The Medical Director works actively to implement and administer medical policies, disease and medical care management programs, integrate physician services, quality assurance, appeals and grievances, and regulatory compliance programs with medical service and delivery systems to ensure the best possible quality health care for Health Net members. Assists by providing input and recommendations to the various departments within the organization as to policies and procedures that impact the delivery of medical care. Participates actively on quality improvement committees and programs to obtain and ensure continued accreditation with regulatory agencies.

• Supports the Health Plan Chief Medical Officer or Senior Medical Director by effectively implementing the Plan initiatives and programs.
• Leads the effective operational management of assigned departments or functions with an emphasis on execution, outcomes, continual improvement and performance enhancement.
• As a representative of the Health Net Plan, assists in maintaining relationships with key employer groups, physician groups, individual physicians, managed care organizations, and state medical associations and societies.
• Participates in quality improvement programs to assure that members receive timely, appropriate, and accessible health care.
• Provides ongoing compliance with standardized Health Net, Inc. systems, policies, programs, procedures, and workflows.
• Participates and supports communication, education, and maintenance of partnerships with contracted providers, provider physician groups and IPA’s and may serve as the interface between Plan and providers.
• Responsible for recommending changes and enhancements to current managed care, prior authorization, concurrent review, case management, disability review guidelines and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods and treatment protocols.
• May participate in business development, program development, and development of care integration models for increased care delivery efficiency and effectiveness.
• Participates in the administration of medical management programs to assure that network providers deliver and Plan members receive appropriate, high quality, cost effective care.
• Assures compliance with all regulatory, accreditation, and internal requirements and audits.
• Articulates Plan policies and procedures to providers and organizations and works to ensure effective implementation of policies and programs.
• May serve as a member on quality and/or care management programs and committees as directed.
• Analyzes population-based reports to refine management activities, investigate and define variation, and ensure conformance to expected standards and targets.
• Investigates selected cases reported as deviating from accepted standards and takes appropriate actions.
• Actively interfaces with providers (hospitals, PPG’s, IPA’s) to improve health care outcomes, health care service utilization and costs.
• Analyzes member and population data to guide and manage program direction such as ensuring that members enroll in clinical programs indicated by their clinical need.
• Leads and/or supports resolution of member or provider grievances and appeals
• Optimizes utilization of medical resources to maximize benefits for the member while supporting Health Net Plans and Health Net corporate initiatives.
• Collaborates with Provider Network Management on the network strategy and may meet with Provider Network Management to ensure effective execution of the strategy.
• Assists in the analysis of performance data of physicians and hospitals and the development and implementation of a corrective action plan.
• Works to ensure/support appropriate implementation of policies and procedures to maintain compliance with accreditation and regulatory agencies.
• Supports state regulatory relationships and may serve as the lead physician for state and federal medical management regulatory audits (i.e., NCQA, HEDIS, URAC).
• Actively supports Quality and Compliance to ensure that Health Net meets and exceeds medical management, regulatory, agency, and quality standards.
• Provides effective and active medical management leadership.
• Serves on quality and care management teams and committees.
• Performs all other duties as assigned.

Education/Experience: Graduate of an accredited medical school;