[Hiring] Medical Director @Magellan Health

Role Description

This is a remote position requiring active Hawaii licensure. Both full-time and part-time candidates will be considered.

This position supports the clinical vision for the health plan(s) for all lines of business (Medicaid, Medicare, and Commercial) and implements programs to support this vision. May serve multiple health plans managed by the Clinical Center of Excellence.

• Provides clinical leadership to the interdisciplinary Medical Management team.
• Includes clinical/medical oversight of clinical team members and consultation and training with care managers.
• Addresses cost and quality of care.
• Provides day-to-day physician oversight to an assigned interdisciplinary UM team.
• Regular involvement in the case management of at-risk cases and medical necessity decisions.
• Follows high-risk cases throughout the treatment continuum.
• Ensures coordinated care for persons with severe, complex, and/or treatment-resistant illnesses.
• Continues physician oversight of at-risk patients for complex case management.
• Involvement in the development of case management plans.
• Develops and implements a Utilization Management program and action plan.
• Evaluates the effectiveness of UM practices and criteria.
• Actively monitors for over- and under-utilization.
• Assumes a leadership position in knowledge, implementation, training, and supervision of medical necessity criteria.
• Implements clinical practice standards and policies developed by Magellan corporate.
• Develops, implements, and interprets medical policy, technology assessments, and medical necessity guidelines.
• Develops effective working relationships with practitioners, provider facilities, and treatment programs.
• Confers directly with psychiatrists and other practitioners regarding patient care.
• Identifies and follows up on quality of care concerns with involved practitioners and facilities.
• Ensures compliance with contract requirements, accreditation standards, state policies, and federal policies.
• Participates in continuous quality improvement efforts.
• Maintains the integrity of the appeals process, both internally and externally.
• Responsible for investigating adverse incidents and quality of care concerns.
• Participates in preparation for NCQA and URAC certifications.
• Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA).
• Supports senior medical director in designing and implementing medical action plans.
• Supports senior medical director in parity analyses and documentation.
• Participates in committee work and JOC (Joint Operations Committee).
• Maintains licensure requirements for other states as assigned.
• Provides after-hours coverage.
• May need to work beyond typical business hours to meet health plan and Magellan deliverables.
• Other duties as assigned.

Qualifications

• Targeted specialties are Psychiatry, Psychiatric sub-specialty, Primary Care, Geriatrics, Palliative Care, or Physical Medicine.
• Doctor of Medicine (MD) degree OR Doctor of Osteopathic Medicine (DO) degree OR Bachelor of Medicine, Bachelor of Surgery (MBBS) international degree with successful completion of United States based internship and residency.
• Successful completion of the ECFMG and FLEX examinations.
• Full training in a residency program in the United States or Canada approved by the Accreditation Council for Graduate Medical Education (ACGME).
• Post-residency experience of at least 3 years involving substantial direct patient care.
• Clinical experience pertinent to the patient population(s) being managed.
• Unrestricted current and valid license or certification to practice medicine in a state or territory of the United States.
• Ability and desire to lead through and effect appropriate changes.
• Experience with cost-benefit analysis, medical decision analysis, credentialing, quality assurance, and continuous quality improvement (CQI) processes.

Requirements

• After Hours coverage may be required.

Benefits

• This position may be eligible for short-term incentives as well as a comprehensive benefits package.
• Magellan offers a broad range of health, life, voluntary, and other benefits and perks that enhance your physical, mental, emotional, and financial wellbeing.

Company Description

Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.

Every employee must understand, comply with, and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.