Senior Medical Director Appeals, National Physical Health UM Team

Location: California

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:

** Lead a team of medical directors and supervise MD’s responsible for utilization management and appeals functions to ensure members receive medically necessary, evidence-based care aligned with bet practice promoting safety, quality and cost of care outcomes. Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit in collaboration with Operations, Health plan leaders and cross functional stakeholders across the enterprise.
* Provide medical leadership for all utilization management (appeals), pharmacy, case management, disease management, cost containment, and medical quality improvement activities.
* Develop and have oversight of training and expertise for Medicare appeals reviews, ALJ hearings. Have oversight of STARS metrics related to appeals and collaborate with key stakeholders for IRE challenges
* Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
* 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.
* Assist in the development and implementation of physician education with respect to clinical issues and policies.
* Identify utilization review studies and evaluate 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.
* Advanced degree in health care management, informatics preferred but not required
* Management experience, 5 years or more of leading large physician teams in a matrixed environment, preferred.
* Deep knowledge of Medicare policies and procedures (Manuals, NCD’s, LCD’s, final rules, STARS metrics) and previous experience leading Medicare Appeals, IRE and ALJ hearings, STARS metrics
* Previous experience with…