What are the responsibilities and job description for the Clinical Director of Medical Excellence position at Cenetene Corporation?
You could be the one who makes a profound impact on the lives of our members as a clinical professional. We are a national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Job Summary
This role assists the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions.
- Provides medical leadership for utilization management, cost containment, and medical quality improvement activities.
- Performs medical review activities related to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
- Supports effective implementation of performance improvement initiatives for capitated providers.
- Assists the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service.
- Provides medical expertise in the operation of approved quality improvement and utilization management programs.
- Assists the Chief Medical Director in the functioning of physician committees, including committee structure, processes, and membership.
- Conducts regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams.
- Collaborates effectively with clinical teams, network providers, appeals teams, and medical consultants for reviewing complex cases.
- Participates in provider network development and new market expansion.
- Assists in the development and implementation of physician education regarding clinical issues and policies.
- Identifies utilization review studies and evaluates adverse trends in utilization of medical services.
- Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice.
