Medical Director (BH, UM) Remote HI

Magellan Health • Honolulu, HI

2d • $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 requires active Hawaii licensure. Both full-time and part-time candidates will be considered.

The position provides clinical leadership and physician oversight to interdisciplinary Medical Management and Utilization Management teams. It includes consultation and training for care managers, involvement in at-risk case management, medical necessity decisions, and oversight of high-risk cases throughout treatment—from inpatient and rehabilitation care through partial hospitalization, outpatient care, and other levels. The Medical Director helps ensure people with severe, complex, or treatment-resistant illnesses receive medically necessary, coordinated care, and participates in developing case management plans.

The role develops and implements utilization management programs and action plans focused on high-quality, cost-effective care; evaluates UM practices and criteria; monitors for over- and under-utilization; and leads the implementation, training, and supervision of medical necessity criteria. In collaboration with the Corporate Clinical team, the Medical Director implements clinical standards and policies and develops, implements, and interprets medical policy, technology assessments, and medical necessity guidelines.

The Medical Director works with practitioners, provider facilities, treatment programs, and potentially client organizations. The role includes peer review and educational interventions, follow-up on quality-of-care concerns, and implementation of contract, accreditation, state, and federal requirements. It contributes to continuous quality improvement, appeals, adverse incident investigations, NCQA and URAC preparation, and NCQA-compliant quality improvement activities. Additional work includes supporting senior medical leadership with medical action plans and parity analyses, committee and Joint Operations Committee participation, maintaining other state licenses as assigned, and providing after-hours coverage. Work beyond typical business hours may be needed to meet deliverables. Other duties may be assigned.

Requirements

• MD, DO, or MBBS degree; an international MBBS holder must have completed a U.S.-based internship and residency, and subspecialists must also have completed a U.S.-based fellowship.
• 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 three 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; this remote position requires active Hawaii licensure.
• Required physician licensure and board certification (ABMS or specialty board), as applicable to the MD, DO, or MBBS credential.
• Ability and desire to lead and effect appropriate change.
• Experience with cost-benefit analysis, medical decision analysis, credentialing, quality assurance, and continuous quality improvement processes.
• Targeted specialties are Psychiatry, a psychiatric subspecialty, Primary Care, Geriatrics, Palliative Care, or Physical Medicine.
• After-hours coverage may be required.

Responsibilities

• Support the clinical vision for health plans across Medicaid, Medicare, and Commercial lines of business, and implement programs supporting that vision.
• Provide clinical leadership and medical oversight to interdisciplinary Medical Management team members; consult with and train care managers.
• Provide day-to-day physician oversight to an assigned interdisciplinary UM team, including at-risk case management and medical necessity decisions.
• Follow high-risk cases across the treatment continuum and help ensure medically necessary, coordinated care for people with severe, complex, or treatment-resistant illnesses.
• Provide ongoing physician oversight of 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 Utilization Management programs and action plans that promote high-quality care in the most cost-effective setting.
• Evaluate UM practices and criteria, monitor for over- and under-utilization, and lead the implementation, training, and supervision of 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, as applicable, client organizations.
• Confer with psychiatrists and other practitioners about care through peer review and educational interventions.
• Identify and promptly follow up on quality-of-care concerns involving practitioners, provider facilities, and treatment programs.
• Ensure implementation of client contract requirements, accreditation standards, and state and federal policies.
• 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 the clinical lead senior medical director and quality improvement staff.
• Participate in committees and project teams as directed by the senior medical director or vice-president.
• Support the senior medical director in designing and implementing medical action plans and in 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 work beyond typical business hours when needed to meet health plan and Magellan deliverables.
• Perform other duties as assigned.
• Understand, comply with, and attest to position-specific security responsibilities and controls, and comply with applicable legal, regulatory, contractual, and internal requirements.

Benefits

• Short-term incentives may be available.
• Comprehensive benefits package.
• Health, life, voluntary, and other benefits and perks intended to support 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