Medical Director (BH, UM) Remote HI

Magellan Health • Honolulu, HI

23h • $200,280 - $360,500 • Remote

About The Position

The Medical Director supports the clinical vision for health plans across Medicaid, Medicare, and Commercial lines of business and implements programs to advance that vision. The role may serve multiple health plans managed by the Clinical Center of Excellence and provides clinical leadership to the interdisciplinary Medical Management team, including medical oversight, consultation, and training for clinical team members and care managers to address cost and quality of care.

The Medical Director provides day-to-day physician oversight to an assigned interdisciplinary Utilization Management (UM) team, regularly participates in managing at-risk cases and making medical necessity decisions, and follows high-risk cases across the treatment continuum. The role ensures people with severe, complex, or treatment-resistant illnesses receive medically necessary, coordinated care; oversees patients in complex case management; and supports timely completion of utilization management activities. The Medical Director also contributes to case management plans and develops and implements UM programs and action plans that promote high-quality care in the most cost-effective setting.

The role evaluates UM practices and criteria, monitors for over- and under-utilization, and leads the understanding, implementation, training, and supervision of medical necessity criteria. In collaboration with the Corporate Clinical team, the Medical Director implements clinical practice standards and policies and develops, implements, and interprets medical policy, technology assessments, and medical necessity guidelines. The position builds relationships with practitioners, provider facilities, treatment programs, and potentially client organizations, and consults with practitioners through peer review and educational interventions. It identifies and follows up on quality-of-care concerns.

The Medical Director ensures implementation of applicable contract requirements, accreditation standards, and state and federal policies; supports continuous quality improvement and compliance in utilization and case management; and maintains the integrity of internal and external appeals processes. Responsibilities also include investigating adverse incidents and quality-of-care concerns, preparing for NCQA and URAC certifications, and leading NCQA-compliant clinical quality improvement activities in collaboration with the clinical lead senior medical director and quality improvement staff. The position may participate in committees and project teams, support the senior medical director with medical action plans and parity analyses, participate in committee work and the Joint Operations Committee, maintain additional state licensure as assigned, and provide after-hours coverage. Work beyond typical business hours may be needed to meet health plan and Magellan deliverables. Duties listed are representative and not all-inclusive; additional duties may be assigned in keeping with the role.

This is a remote position requiring active Hawaii licensure. Both full-time and part-time candidates will be considered. The targeted specialties are Psychiatry, psychiatric subspecialty, Primary Care, Geriatrics, Palliative Care, or Physical Medicine. The position offers a stated base salary range of $200,280 to $360,500; actual pay may vary with location and job-related factors. The position may be eligible for short-term incentives and a comprehensive benefits package.

Requirements

• Active Hawaii medical licensure is required for this remote position.
• MD, DO, or international MBBS degree with successful completion of a United States-based internship and residency; subspecialists must also have completed a United States-based fellowship.
• Successful completion of the ECFMG and FLEX examinations.
• Full residency training in a United States or Canadian program approved by the Accreditation Council for Graduate Medical Education (ACGME).
• At least 3 years of post-residency experience involving substantial direct patient care at multiple levels of care.
• Clinical experience pertinent to the patient populations being managed.
• Unrestricted, current, and valid license or certification to practice medicine in a United States state or territory.
• Board certification by ABMS or a specialty board.
• Ability and desire to lead and effect appropriate changes.
• Experience with cost-benefit analysis, medical decision analysis, credentialing, quality assurance, and continuous quality improvement (CQI) processes.
• Ability to provide after-hours coverage as required.

Nice To Haves

• Targeted specialty in Psychiatry, a psychiatric subspecialty, Primary Care, Geriatrics, Palliative Care, or Physical Medicine.

Responsibilities

• Support the clinical vision for health plans across Medicaid, Medicare, and Commercial lines of business and implement supporting programs.
• Provide clinical leadership and medical oversight to the interdisciplinary Medical Management team, including consultation and training with care managers.
• Provide day-to-day physician oversight to an assigned interdisciplinary UM team, including involvement in at-risk case management and medical necessity decisions.
• Follow high-risk cases throughout the treatment continuum and ensure medically necessary coordinated care for people with severe, complex, or treatment-resistant illnesses.
• Continue physician oversight of at-risk patients in complex case management and ensure timely completion of utilization management activities.
• Participate in developing case management plans.
• Develop and implement a Utilization Management program and action plan focused on high-quality care in the most cost-effective setting.
• Evaluate UM practices and criteria and monitor for over- and under-utilization.
• Lead knowledge, implementation, training, and supervision related to medical necessity criteria.
• Implement corporate clinical practice standards and policies and develop, implement, and interpret medical policy, technology assessments, and medical necessity guidelines.
• Build working relationships with practitioners, provider facilities, treatment programs, and potentially client organizations; confer with practitioners through peer review and educational interventions.
• Identify and promptly follow up on quality-of-care concerns involving practitioners, facilities, and treatment programs.
• Ensure applicable contract requirements, accreditation standards, and state and federal policies are implemented.
• Work with teams on continuous quality improvement and ongoing compliance in utilization and case management.
• Participate in and maintain the integrity of internal and external appeals processes.
• Investigate adverse incidents and quality-of-care concerns.
• Participate in preparation for NCQA and URAC certifications.
• Develop and provide leadership for NCQA-compliant clinical quality improvement activity in collaboration with the clinical lead senior medical director and quality improvement staff.
• Participate in committees and project teams as directed; support the senior medical director with medical action plans and parity analyses and documentation; participate in committee work and the Joint Operations Committee.
• Maintain licensure requirements for other states as assigned by the senior medical director and CMO.
• Provide after-hours coverage and, as needed, work beyond typical business hours to meet health plan and Magellan deliverables.
• Perform other duties assigned in keeping with the intent of the role.

Benefits

• The position may be eligible for short-term incentives.
• Comprehensive benefits package covering health, life, voluntary, and other benefits and perks supporting physical, mental, emotional, and financial well-being.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree