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Medical Director

Company: Gelsi Ltd
Location: Tuttle
Posted on: April 11, 2021

Job Description:

Position Purpose: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
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  • 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 committeesEducation/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. Get tailored job recommendations based on your interests. Category Finance & Actuarial Location Indianapolis, Indiana, US Category IT Location Charlotte, North Carolina, US Category Clinical & Care Management Location Little Rock, Arkansas, US Transforming the health of the community, one person at a time. HEALTHCARE IS BEST DELIVERED LOCALLY Our local approach allows us to help members access high-quality, culturally sensitive healthcare services. LOCAL COMMUNITY INVOLVEMENT IS KEY We invest in local communities and the lives of our members in as many ways as we can. Stay safe from recruitment fraud! The only way to apply for a position at Centene is via our careers website. Learn how to protect yourself from recruitment fraud. You have the talent. We have the career to match. Let's get started.

Keywords: Gelsi Ltd, Norman , Medical Director, Executive , Tuttle, Oklahoma

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