? (Urgent Search) Medical Director, LTSS – Delaware Position Available In Pope, Arkansas

Job Description:

You could be the one who changes everything for our 28 millionmembers as a clinical professional on our Medical Management/HealthServices team. Centene is a diversified, national organizationoffering competitive benefits including a fresh perspective onworkplace flexibility.

Position Purpose:

Assist the Chief MedicalOfficer to oversee the medical management and quality improvementinitiatives for both the Long-Term Services and Supports (LTSS) andMedicare-Medicaid Duals populations. Additionally, the MedicalDirector will collaborate with other key stakeholders to provideleadership in utilization management and cost effectiveness whileensuring compliance with regulatory and accreditation standards .This person shall oversee and be responsible for all LTSS,including oversight and consultation with care coordinators andcase managers and oversight of coordination with State agencies.

Medical Leadership and Oversight:

• Provide medical leadership forutilization management, case management, cost containment, andquality improvement activities within the LTSS andMedicare-Medicaid Duals populations.
• Review complex,controversial, or experimental medical services through medicalreview processes, ensuring timely, evidence-based decision-making
• Assist the Chief Medical Officer (CMO) in planning and settinggoals to improve care quality and cost-effectiveness for members.
• Collaborate with leadership teams to develop and implementstrategies for operational and clinical improvements in the LTSSand Medicare-Medicaid Duals populations.

Utilization Management &Quality Improvement:

• Provide medical expertise in the operationof utilization management (UM) programs and quality improvementinitiatives to ensure compliance with regulatory, state, corporate,and accreditation requirements.
• Conduct reviews of members’ careto determine medical necessity based on established guidelines andclinical judgment.
• Analyze utilization patterns and trends toidentify areas for improvement, including reviewing unusualprovider practice patterns and addressing adverse trends in serviceuse.
• Conduct regular clinical rounds, including interdisciplinaryteam (IDT) rounds, complex case reviews, and Nursing FacilityTransition (NFT) rounds to optimize member care.
• Participate inthe development and execution of physician education programsrelated to clinical policies and best practices.

Care Coordinationand Provider Collaboration:

• Collaborate with the LTSS Directorand Care Coordination Director to manage and optimize LTSS andMedicare-Medicaid Duals program operations, focusing on improvingquality metrics and member outcomes.
• Work closely with clinicalteams, case managers, and community stakeholders to ensure theeffective delivery of care and coordination for high-risk andcomplex members.
• Participate in provider network development,expansion, and ongoing relationships to support high-quality carefor Medicare-Medicaid Dual and LTSS members.
• Interface withphysicians, providers, and community organizations to support caredelivery, improve health outcomes, and enhance member satisfaction.

Regulatory Compliance and Reporting:

• Ensure the LTSS andMedicare-Medicaid Duals programs meet regulatory and accreditationstandards, including participating in audits and preparing forregulatory reviews.
• Represent the MCO at relevant statecommittees, medical groups, and other ad hoc committees.
• Monitorand report on key performance indicators (KPIs) related to medicalcare quality, utilization patterns, and clinical outcomes.

Education and Process Improvement:

• Identify opportunities forclinical quality improvement initiatives to reduce unwarrantedvariation in practice and improve care efficiency.
• Providetraining to case managers, care teams, and providers to improveclinical assessments, care planning, and service delivery.
• Develop and implement strategies to improve the overall quality andoutcomes of care for the LTSS and Medicare-Medicaid Dualspopulations.

• Transactional UM Reviews and Complex CaseManagement:

• Conduct medical reviews for utilization management,including the assessment of medical necessity, service requests,and appeals, with a focus on clinical appropriateness.
• Leadand/or participate in complex case management reviews, ensuringthat complex cases are addressed appropriately and expeditiously.
• Collaborate with medical, pharmacy, and utilization managementteams on the review of complex, high-cost, or specialty care cases.

Other Duties:

Perform other duties as assigned by the Chief MedicalOfficer to support the MCO’s mission, goals, and initiatives

Education/Experience:

Medical Doctor or Doctor of Osteopathy.

Utilization Management experience and knowledge of qualityaccreditation standards preferred. Actively practices medicine.

Course work in the areas of Health Administration, HealthFinancing, Insurance, and/or Personnel Management is advantageous.

Experience treating or managing care for a culturally diversepopulation preferred.

DE LTSS Only:

A full-time Long Term Servicesand Supports Medical Officer/Medical Director (LTSS CMO) who is aboard certified physician with experience in LTSS. This personshall oversee and be responsible for all LTSS, including oversightand consultation with care coordinators and case managers andoversight of coordination with State agencies. Experience with DualSpecial Needs Plans (DSNP) or Medicare/Medicaid populations ishighly desirable

License/Certifications:

Board certification in amedical specialty recognized by the American Board of MedicalSpecialists or the American Osteopathic Association’s Department ofCertifying Board Services. Current Delaware state license as a MDor DO without restrictions, limitations, or sanctions fromgovernment programs.

Pay Range:

$210,800.00

• $400,500.

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 flexibleapproach to work with remote, hybrid, field or office workschedules. Actual pay will be adjusted based on an individual’sskills, experience, education, and other job-related factorspermitted by law. Total compensation may also include additionalforms of incentives. Centene is an equal opportunity employer thatis committed to diversity, and values the ways in which we aredifferent. All qualified applicants will receive consideration foremployment without regard to race, color, religion, sex, sexualorientation, gender identity, national origin, disability, veteranstatus, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will beconsidered in accordance with the LA County Ordinance and theCalifornia Fair Chance Act