Description
Position Purpose: Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit. Oversee the denials and appeals department. May manage other medical directors. Assume VPMA responsibility in absence of VPMA.
Key Details:
Serve as Clinical Executive leader representing the health plan both internally and externally; specifically serving in the role as physician executive leader with NH Department of Health and Human Services on all clinical escalations, state fair hearings and health plan advocacy. The Senior Medical Director must be located in New Hampshire or willing to relocate.
- Provide medical leadership for all utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement activities.
- Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
- Support the effective implementation of performance improvement initiatives for capitated providers.
- Assist VPMA in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
- Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
- Assist the VPMA in the functioning of the physician committees including committee structure, processes, and membership.
- Oversee the activities of physician advisors and other medical directors.
- Utilize the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
- Participate in provider network development and new market expansion as appropriate.
- Participate in provider profiling initiatives.
- Assist in the development and implementation of physician education with respect to clinical issues and policies.
- Identify utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
- Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice by profiling providers in order to improve the quality and cost of care.
- Interface with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
- Review claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
- May develop 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.
- Represent the business unit at appropriate state committees and other ad hoc committees.
- May oversee all aspects of the Appeals and Denials department including implementing budgetary, policy, and personnel decisions for the department.
- Work flexible hours to ensure adequate staffing levels and coverage, including weekends and holidays, to meet patient care needs and support case coverage.
- 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.
- Managed care or ACO leadership experience strongly preferred.
- Management experience preferred.
- Utilization Management experience and knowledge of quality accreditation standards preferred.
- Actively practices medicine.
- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
- 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 or the American Osteopathic Association’s Department of Certifying Board Services.
- Active American Board Certification in Internal or Family Medicine, preferred. Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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
