Centene is transforming the health of our communities one person at a time.  As an Executive on our team, you could be the one who changes everything for our 28 million members.
 

Position Purpose: Provide medical oversight, expertise and leadership to ensure the delivery of cost effective, quality healthcare services to health plan members.

• Serves as clinical advisor to and educator of medical management staff making sure correct clinical judgment is applied to all medical management determinations.

• Provide leadership and expertise in the development, implementation and interpretation of medical review and quality related policies and guidelines.

• Provide oversight and direction for staff and provider training and education.

• Promote positive relations with the local medical community, including periodic consultation with providers or prescribers.

• Review case management data, identifies trends and gaps in care and recommends corrective actions.

• Review all quality of care issues and oversees the development and implementation of processes for improvement.

• Monitor performance indicators to ensure the delivery of cost-effective care within quality standards.

• Monitor member and provider satisfaction and recommends and implements changes to improve satisfaction levels.

• Work collaboratively to develop corporate clinical care standards and medical practice policies.

• Provide medical guidance to the Medical Management department.

• For Home State Health Plan only – responsible for the sufficiency and supervision of the health plan provider network.

• Additional responsibilities for Pennsylvania Health & Wellness;

• Available to the CHC-MCO's medical staff for consultation on referrals, denials, complaints and problems.

• Directly involved in the CHC-MCO's recruiting and credentialing activities.

• Familiar with local standards of medical practice and nationally accepted standards of practice, including those for LTSS and with "most integrated setting" requirements under the ADA.

• Knowledge of due process procedures for resolving issues between Network Providers and the CHC-MCO administration, and between participants and the CHC-MCO, including those related to medical decision making and utilization review.

• Available to review, advise and take action on questionable hospital admissions, Medically Necessary days and all other medical care and medical cost issues.

• Directly involved in the CHC-MCO's process for prior authorizing or denying services and is available to interact with Providers on denied authorizations.

• Knowledge of current peer review standards and techniques.

• Knowledge of risk management standards.

• Directly accountable for all Quality Management and Utilization Management activities.

• Oversees and is accountable for: (a) referrals to the Department and appropriate agencies for cases involving quality of care and services that have adverse effects or outcomes; and (b) the processes for potential Fraud, Waste, and Abuse audit, investigation, review, sanctioning and referral to the appropriate oversight agencies.

• Additional responsibilities for SilverSummit Health Plan;

• Directly accountable for all Quality Management and Utilization Management activities, including but not limited to the Interqual Quality Assurance Program assessment, serving as the committee chair and other duties as required.

• Oversees and is accountable for: (a) referrals to the Department and appropriate agencies for cases involving quality of care and services that have adverse effects or outcomes; and (b) the processes for potential Fraud, Waste, and Abuse audit, investigation, review, sanctioning and referral to the appropriate oversight agencies.

• Oversees the development and revision of the contractor’s clinical care standards and practice guidelines.

• Oversees provider recruitment and credentialing activities.

• Ensures Individual Education Programs and Member Individual Family Service Plans are followed.

• Available to the MCO's medical staff for consultation on referrals, denials, complaints and problems.

• Knowledge of due process procedures for resolving issues between Network Providers and the MCO administration, and between participants and the CHC-MCO, including those related to medical decision making and utilization review.

• Directly involved in the MCO's process for prior authorizing or denying services and is available to interact with Providers on denied authorizations.
• Performs other duties as assigned

• Complies with all policies and standards

Education/Experience: Medical Doctor or Doctor of Osteopathy. 7+ years of clinical experience in the practice of medicine. Management experience preferred. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine and provides leadership in the local medical community. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is desired. Experience treating or managing care for a culturally diverse population preferred.

License/Certification: Board certification in a medical specialty recognized by the American Board of Medical Specialists. (Certification in a primary care specialty preferred.) Current state license as a MD or DO without restrictions, limitations or sanctions from government programs.

 

Pay Range: $268,700.00 - $510,500.00 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.  Total compensation may also include additional forms of incentives.

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