Director of Clinical Operations

4 days ago

Canada Centene Corporation Full time

Drive Quality Healthcare Transformation as a Senior Medical Leader

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Join us at Centene Corporation as a senior medical leader in our Medical Management/Health Services team, where you'll play a pivotal role in shaping the future of healthcare.

This dynamic role is part of our innovative organization that prioritizes forward-thinking approaches to work-life balance and flexibility.

The Position Purpose: Collaborate with the Chief Medical Director to drive medical management, quality improvement, and credentialing functions for the business unit.

  1. Develop and execute strategic plans for utilization management, cost containment, and medical quality improvement activities.
  2. Conduct thorough medical reviews of complex, controversial, or experimental medical services.
  3. Support the effective implementation of performance improvement initiatives for capitated providers.
  4. Collaborate with the Chief Medical Director to establish goals and policies enhancing quality and cost-effectiveness of care and service for members.
  5. Offer expert medical guidance in the operation of approved quality improvement and utilization management programs according to regulatory, state, corporate, and accreditation requirements.
  6. Assist the Chief Medical Director in managing physician committees, including committee structure, processes, and membership.
  7. Lead regular rounds to assess and coordinate care for high-risk patients, collaborating closely with care management teams to optimize outcomes.
  8. Cultivate relationships with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
  9. Participate in provider network development and new market expansion as needed.
  10. Develop and implement physician education regarding clinical issues and policies.
  11. Analyze utilization review studies to identify adverse trends in medical services usage, unusual provider practice patterns, and benefit/payment adequacy.
  12. Identify opportunities for clinical quality improvement studies to reduce unwarranted variation in clinical practice, enhancing the quality and cost of care.
  13. Interface with physicians and other providers to facilitate implementation of recommendations to improve utilization and healthcare quality.
  14. Review claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment.
  15. Foster alliances with the provider community through the development and implementation of medical management programs.
  16. Represent the business unit before various publics locally and nationally on medical philosophy, policies, and related issues.
  17. Represent the business unit at relevant state committees and other ad hoc committees.
  18. May require weekend and holiday work to support business operations, as needed.

About You: We seek a Medical Doctor or Doctor of Osteopathy with a strong background in utilization management and quality accreditation standards. Actively practicing medicine is essential. Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population is preferred.

Licensure/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. A current California state license as a MD or DO without restrictions, limitations, or sanctions from government programs is required.

Total Rewards: At Centene, we offer a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and flexible work arrangements. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional incentives.

Centene is an equal opportunity employer 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.

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