Position Purpose: Assist the CMO to direct and coordinate the physician component of the utilization management functions for the health plan business units.

Key Details: Must be Board Certified Physician with an active Indiana MD or DO state license. The ideal candidate will reside in Indiana and have utilization management experience. This role is roughly 20 hours per week with Thursdays/Fridays being the highest priority.

• Provides medical leadership for utilization management activities and medical review activities pertaining to utilization review, quality assurance, medical review of complex, and controversial or experimental medical services such as transplants utilizing the services of consultants
• Performs case reviews and appeals for all health plans.
• Assists CMO in planning, 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.
• 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.
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment

Education/Experience:

• Requires a Medical Doctor or Doctor of Osteopathy, board certified preferably in a primary care specialty (Internal Medicine, Med/Peds, Family Practice, Pediatrics or Emergency Medicine) or other specialty familiar with Medicare patients.
• Previous experience within a managed care organization is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred.
• Experience treating or managing care for a culturally diverse population preferred. The candidate must be an actively practicing physician. More than 1 state license is preferred.

License/Certifications:

• Board Certification through American Board Medical Specialties.
• Current Indiana state medical license without restrictions.

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