What are the responsibilities and job description for the Medical Director (PRN) - Hawaii position at Ohana Health Plan?
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 VP of Clinical Programs to direct and coordinate the physician component of the utilization management functions for the health plan business units.
- Provides medical leadership for utilization management activities and medical review activities pertaining to utilization review, quality assurance, medical review of complex, and controversial or experimental medical services such as transplants utilizing the services of consultants
- Performs case reviews and appeals for all health plans.
- Assists VP of Clinical Programs in planning, establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
- Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
- Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit / payment components.
- Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
- Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
Education / Experience : Requires a Medical Doctor or Doctor of Osteopathy, board certified preferably in a primary care specialty (Internal Medicine, Med / Peds, Family Practice, Pediatrics or Emergency Medicine) or other specialty familiar with Medicare patients. Previous experience within a managed care organization is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and / or Personnel Management is preferred. Experience treating or managing care for a culturally diverse population preferred. The candidate must be an actively practicing physician. More than 1 state license is preferred.
License / Certifications : Board Certification through American Board Medical Specialties. Current Hawaii state medical license without restrictions.
Pay Range : $101.35 - $192.54 per hour
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
Salary : $101 - $193
