Medical Director, LTSS - Delaware

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 Officer to oversee the medical management and quality improvement initiatives for both the Long-Term Services and Supports (LTSS) and Medicare-Medicaid Duals populations. Additionally, the Medical Director will collaborate with other key stakeholders to provide leadership in utilization management and cost effectiveness while ensuring compliance with regulatory and accreditation standards. This person shall oversee and be responsible for all LTSS, including oversight and consultation with care coordinators and case managers and oversight of coordination with State agencies.

Medical Leadership and Oversight:

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

Utilization Management & Quality Improvement:

• Provide medical expertise in the operation of utilization management (UM) programs and quality improvement initiatives to ensure compliance with regulatory, state, corporate, and accreditation requirements.
• Conduct reviews of members’ care to determine medical necessity based on established guidelines and clinical judgment.
• Analyze utilization patterns and trends to identify areas for improvement, including reviewing unusual provider practice patterns and addressing adverse trends in service use.
• Conduct regular clinical rounds, including interdisciplinary team (IDT) rounds, complex case reviews, and Nursing Facility Transition (NFT) rounds to optimize member care.
• Participate in the development and execution of physician education programs related to clinical policies and best practices.

Care Coordination and Provider Collaboration:

• Collaborate with the LTSS Director and Care Coordination Director to manage and optimize LTSS and Medicare-Medicaid Duals program operations, focusing on improving quality metrics and member outcomes.
• Work closely with clinical teams, case managers, and community stakeholders to ensure the effective delivery of care and coordination for high-risk and complex members.
• Participate in provider network development, expansion, and ongoing relationships to support high-quality care for Medicare-Medicaid Dual and LTSS members.
• Interface with physicians, providers, and community organizations to support care delivery, improve health outcomes, and enhance member satisfaction.

Regulatory Compliance and Reporting:

• Ensure the LTSS and Medicare-Medicaid Duals programs meet regulatory and accreditation standards, including participating in audits and preparing for regulatory reviews.
• Represent the MCO at relevant state committees, medical groups, and other ad hoc committees.
• Monitor and report on key performance indicators (KPIs) related to medical care quality, utilization patterns, and clinical outcomes.

Education and Process Improvement:

• Identify opportunities for clinical quality improvement initiatives to reduce unwarranted variation in practice and improve care efficiency.
• Provide training to case managers, care teams, and providers to improve clinical assessments, care planning, and service delivery.
• Develop and implement strategies to improve the overall quality and outcomes of care for the LTSS and Medicare-Medicaid Duals populations.

Transactional UM Reviews and Complex Case Management:

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

Other Duties: Perform other duties as assigned by the Chief Medical Officer to support the MCO’s mission, goals, and initiatives.

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.

DE LTSS Only: A full-time Long Term Services and Supports Medical Officer/Medical Director (LTSS CMO) who is a board certified physician with experience in LTSS. This person shall oversee and be responsible for all LTSS, including oversight and consultation with care coordinators and case managers and oversight of coordination with State agencies. Experience with Dual Special Needs Plans (DSNP) or Medicare/Medicaid populations is highly desirable.

License/Certifications: Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services. Current Delaware state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

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. 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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.