MHS Wisconsin, a part of Centene Corporation, is seeking a Chief Medical Director. Reporting to the President and Chief Executive Officer, the Chief Medical Director will be responsible for the development and implementation of the overall clinical strategy. This role will promote positive relationships and foster closer ties across the provider community, to the benefit of the communities served. The Chief Medical Director will also provide leadership and expertise in new and innovative medical management approaches to drive high quality clinical outcomes, while ensuring the delivery of cost-effective care. This role will direct and coordinate the medical management, quality improvement and credentialing functions in support of the strategic vision, policies and procedures. S/he also will have oversight of pharmacy and medical directors, which includes approximately six direct reports.
Centene serves more than 25 million members through programs and services to government sponsored healthcare programs, focusing on under-insured and uninsured individuals. Fortune Magazine has ranked Centene Corporation No. 24 in its 2021 FORTUNE 500 list of largest corporations in the United States, ranked by revenue, up from the 61st spot in 2018. With over 400,000 covered lives, MHS is Centene’s second oldest health plan, establishing operations 22 years ago, and remains one of Centene’s top performing plans nationwide. MHS was the first Medicaid managed care plan in the state of Wisconsin, and today includes Medicaid, ABD, TANF, and Medicare Advantage populations with a 4-STAR rating.
- Serves as clinical advisor to and educator of medical management staff making sure correct clinical judgment is applied to all medical management determinations.
- Oversees internal medical review guidelines to ensure clinical integrity and compliance and acts as a resource for staff members throughout the operation.
- Coordinates with other departments responses needed to address regulatory accreditation concerns pertaining to medical management issues.
- Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
- Facilitates the achievement of the Medical Management Program goals through an effective health services delivery system.
- Responsible for physician review and oversight of all potential adverse determinations including pre-certifications/prior authorizations, concurrent review and appeals/ retrospective review.
- Responsible for HEDIS improvement and strategy.
- Actively participates in the auditing process of medical management processes and corrective action team projects for medical management.
- Achieves utilization, cost management and quality goals.
- Participates and advises in the development of corporate medical policies for utilization management, pharmacy, and new technology, and is responsible for the sufficiency and supervision of the health plan provider network.
- Additional responsibilities for the MHS Wisconsin MCO’s medical staff for consultation on referrals, denials, complaints and problems.
- Directly involved in MHS Wisconsin’s recruiting and credentialing activities.
- Familiar with local standards of medical practice and nationally accepted standards of practice, including those for LTSS and with most integrated setting requirements under the ADA.
- Knowledge of due process procedures for resolving issues between Network Providers and the MHS Wisconsin administration, and between participants and the MHS Wisconsin, including those related to medical decision making and utilization review.
- Available to review, advise and take action on questionable hospital admissions, Medically Necessary days and all other medical care and medical cost issues.
- Directly involved in the MHS Wisconsin process for prior authorizing or denying services and is available to interact with providers on denied authorizations.
- Knowledge of current peer review standards and techniques.
- Knowledge of risk management standards.
- Directly accountable for all Quality Management and Utilization Management activities.
- Oversees and is accountable for: referrals to the Department and appropriate agencies for cases involving quality of care and services that have adverse effects or outcomes; and the processes for potential Fraud, Waste, and Abuse audit, investigation, review, sanctioning and referral to the appropriate oversight agencies.
- Medical Doctor or Doctor of Osteopathy.
- Master’s degree in Business Administration, Public Health, Healthcare Administration or related field preferred.
- Board certified in a specialty recognized by the American Board of Medical Specialists.
- Current state medical license without restrictions.
- Leadership experience within a Managed Care Organization preferred.
- Demonstrated ability to create and execute a clinical strategy across a complex organization, garnering support from the provider community and coalescing internal teams.
- Proven experience fostering positive relationships with providers, medical groups, and hospital systems, instilling a vision of shared goals and partnership.
- Strong strategic and innovative approach, with depth in new process development, approaches to new technologies and programs, and performance improvement.
- Passion for improving healthcare for the disadvantaged and underserved, with an understanding of the socio-economic barriers faced by specialized populations. Experience treating or managing care for a culturally diverse population preferred.
- Actively practices medicine and provides leadership in the local medical community.
- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is desired.
- Experience treating or managing care for a culturally diverse population preferred.