Medical Director (BH, UM) - Honolulu, HI

Military Spouse Corporate Career Network • Honolulu, HI

1d • 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 support that vision. The role may serve multiple health plans and provides clinical leadership to the interdisciplinary Medical Management team, including oversight of clinical team members and consultation and training with 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, participates in case management of at-risk cases and medical-necessity decisions, and follows high-risk cases across the treatment continuum. The role helps ensure that people with severe, complex, or treatment-resistant illnesses receive medically necessary, coordinated care; oversees appropriate complex case management; and contributes to case management plans.

The position develops and implements UM programs and action plans to support high-quality, cost-effective care; evaluates UM practices and criteria; monitors over- and under-utilization; and leads the implementation, training, and supervision of medical-necessity criteria. It also implements clinical practice standards and policies, develops and interprets medical policies, technology assessments, and medical-necessity guidelines, and works with practitioners and facilities through peer review and educational interventions.

The Medical Director addresses quality-of-care concerns and adverse incidents, ensures compliance with contract requirements and accreditation standards such as NCQA, and supports continuous quality improvement, appeals, and NCQA and URAC certification activities. The role collaborates on clinical quality improvement activities, medical action plans, parity analyses, committee work, and Joint Operations Committee activities. It may participate in other committees or project teams as directed, maintain additional state licenses as assigned, provide after-hours coverage, and work beyond typical business hours to meet deliverables. Other duties may be assigned.

Requirements

• MD, DO, or international MBBS degree with successful completion of a U.S.-based internship and residency; U.S.-based fellowship completion is required for subspecialists.
• Successful completion of the ECFMG and FLEX examinations.
• Full training in a U.S. or Canadian residency 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 relevant to the patient populations being managed.
• Unrestricted, current, valid license or certification to practice medicine in a U.S. state or territory; active Hawaii licensure is required for this remote position.
• Board certification by an ABMS or 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 processes.
• Ability to provide after-hours coverage as required.

Nice To Haves

• Targeted specialties include 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 programs to support it.
• Provide clinical leadership and oversight to the interdisciplinary Medical Management team, including consultation and training for 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 across levels of care and help ensure medically necessary, coordinated care for people with severe, complex, or treatment-resistant illnesses.
• Oversee at-risk patients appropriate for complex case management and complete utilization management activities in a timely manner.
• Participate in developing case management plans.
• Develop and implement a Utilization Management program and action plan that supports high-quality, cost-effective care.
• Evaluate UM practices and criteria, and monitor for over- and under-utilization.
• Lead knowledge, implementation, training, and supervision in the use of medical-necessity criteria.
• Implement corporate clinical practice standards and policies; 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 psychiatrists and other practitioners about patient care through peer review and educational interventions.
• Identify and promptly follow up on quality-of-care concerns involving practitioners, facilities, and treatment programs.
• Ensure implementation of contract requirements, accreditation standards, and state and federal policies applicable to each client.
• Work with teams on continuous quality improvement and 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 activities with clinical and quality improvement colleagues.
• Support the senior medical director in designing and implementing medical action plans and in parity analyses and documentation.
• Participate in committees and Joint Operations Committee activities, and other project teams as directed.
• 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 deliverables.
• Perform other duties as assigned.

Benefits

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

What This Job Offers

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