Pediatric Medical Director - Director of Clinical Quality

Company: Sunshine State Health Plan
Location: West Palm Beach
Posted on: February 1, 2025

Job Description:

About the RoleAs a seasoned medical professional, you will have the opportunity to shape the future of healthcare for our 28 million members as a key member of our Medical Management/Health Services team at Sunshine State Health Plan.This clinical leadership position reports to the Chief Medical Director and is responsible for directing and coordinating medical management, quality improvement, and credentialing functions for the business unit.Key Responsibilities

• Medical Leadership: Provide medical leadership for all utilization management, cost containment, and medical quality improvement activities.
• Complex Case Review: Perform 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.
• Performance Improvement: Support effective implementation of performance improvement initiatives for capitated providers.
• Quality and Cost-Effectiveness: Assist the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Regulatory Compliance: Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Physician Committee Support: Assist the Chief Medical Director in the functioning of the physician committees, including committee structure, processes, and membership.
• Clinical Care Coordination: Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• Collaboration and Communication: Collaborate effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
• Provider Network Development: Participate in provider network development and new market expansion as appropriate.
• Physician Education: Assist in the development and implementation of physician education with respect to clinical issues and policies.
• Utilization Review and Quality Improvement: Identify utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Clinical Quality Improvement: Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Medical Necessity and Payment: Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
• Medical Management Programs: Develop alliances with the provider community through the development and implementation of the medical management programs.
• Representation and Communication: As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.Requirements
  • Education: Medical Doctor or Doctor of Osteopathy degree.
  • Experience: Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine.
  • Certifications and Licenses: 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 Florida state license as a MD or DO without restrictions, limitations, or sanctions from government programs.About Sunshine State Health PlanCentene 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.Sunshine State Health Plan 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.

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