Behavioral Medical Director - Florida
Company: Sunshine State Health Plan
Location: Pompano Beach
Posted on: October 23, 2024
Job Description:
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: Assist the Chief Medical Director to direct and
coordinate the medical management, quality improvement and
credentialing functions for the business unit.
- 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, ensuring timely
and quality decision making.
- 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.
- Conduct regular rounds to assess and coordinate care for
high-risk patients, collaborating with care management teams to
optimize outcomes.
- Collaborates effectively with clinical teams, network
providers, appeals team, 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 committees.Education/Experience: Medical Doctor or
Doctor of Osteopathy. 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/Certifications, For Behavioral Health only: - Board
certification by the American Board of Psychiatry and Neurology.
Current Florida state medical license without restrictions.
Pay Range: $227,400.00 - $431,900.00 per yearCentene 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.
Keywords: Sunshine State Health Plan, Pompano Beach , Behavioral Medical Director - Florida, Executive , Pompano Beach, Florida
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