We're seeking a board‑certified Medical Director (Internal Medicine or Family Practice) to support our team. This role is fully remote and focuses on utilization management (UM), quality review, and clinical oversight for high‑volume cases.
You will work closely with the Chief Medical Director to ensure timely, accurate, and compliant medical necessity determinations while contributing to process improvements and standardization initiatives across the business unit.
Key Responsibilities
- Provide medical leadership for utilization management, cost‑containment, and quality improvement.
- Perform concurrent inpatient and post‑acute reviews, and review complex/controversial services and claims appeals.
- Support physician committee functions and implement performance improvement initiatives.
- Conduct rounds for high‑risk members and collaborate with care management.
- Develop physician education and provider relationships; represent the business unit as needed.
- Consult on SUD policy and MCM cases when required.
- Review 40–50 medical cases per day using Centene’s EMR and UM systems.
- Determine medical necessity based on InterQual/MCG guidelines and internal standards.
- Conduct complex, controversial, or high‑risk case reviews.
- Collaborate with care management, pharmacy, and appeals teams for clinical decision support.
- Assist with peer review, provider education, and quality improvement initiatives.
- Support corporate goals for cost‑effective, high‑quality care.
- Participate in occasional weekend or holiday coverage on a voluntary basis.
Required
- MD or DO with active, unrestricted U.S. medical license.
- Board certification in a recognized medical specialty (Internal Medicine or Family Practice preferred).
- 4–7 years of clinical experience, with a strong foundation in patient care.
- Proven Utilization Management (UM) experience – payer‑side or hospital UM preferred.
- Proficiency in InterQual, MCG, or equivalent UM frameworks.
Nice to Have
- Experience with managed care organizations, marketplace plans, or corporate UM.
- Multi‑state medical licensure.
- Exposure to clinical policy development, peer review, or quality improvement projects.
- Familiarity with AmBetter or other health plan operations.
Performance Expectations
- Productivity target: ~45+ cases/day.
Seniority Level
Director
Employment Type
Full‑time
Job Function
Management and Health Care Provider
Salary: $190,000.00 – $200,000.00 (United States)
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