Medical Director (BH, UM) - Honolulu, HI

VetJobs • 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 aligned with 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 clinical and medical oversight, consultation, and training.

The position provides day-to-day physician oversight to an assigned interdisciplinary utilization management team, participates in at-risk case management and medical-necessity decisions, and follows high-risk cases across the treatment continuum. It supports coordinated medically necessary care for people with severe, complex, or treatment-resistant illnesses, oversees complex case management when appropriate, and contributes to case management plans.

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

The role builds working relationships with practitioners, provider facilities, treatment programs, and potentially client organizations. It consults directly with practitioners about complex patient care through peer review and educational interventions, follows up on quality-of-care concerns, and helps ensure compliance with contract requirements, accreditation standards, and state and federal policies. It supports continuous quality improvement, appeals, adverse-incident investigations, NCQA and URAC certification preparation, clinical quality improvement activities, committee work, parity analyses, and medical action plans. The position also maintains additional state licensure as assigned, provides after-hours coverage, and may work beyond typical business hours to meet deliverables.

This is a remote position requiring active Hawaii licensure. Both full-time and part-time candidates will be considered. The position may be eligible for short-term incentives and includes a comprehensive benefits package.

Requirements

• Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), or international Bachelor of Medicine, Bachelor of Surgery (MBBS) degree.
• For MBBS candidates, successful completion of a U.S.-based internship and residency; subspecialists must also have successfully completed a U.S.-based fellowship.
• 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).
• At least three 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 U.S. state or territory.
• Active Hawaii licensure is required for this remote position.
• Board certification by ABMS or a specialty board, as listed under required licenses and certifications.
• 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.
• Targeted specialties are 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 that support it.
• Provide clinical leadership and medical oversight to the interdisciplinary Medical Management team, including consultation and training for care managers.
• Provide day-to-day physician oversight to an assigned interdisciplinary utilization management team.
• Participate in at-risk case management and medical-necessity decisions, following high-risk cases across the treatment continuum.
• Ensure medically necessary, coordinated care for people with severe, complex, or treatment-resistant illnesses and provide physician oversight of appropriate complex case management.
• Contribute to case management plans and ensure timely completion of utilization management activities.
• Develop and implement a Utilization Management program and action plan focused on high-quality care and cost-effective care settings.
• Evaluate utilization management practices and criteria, monitor for over- and under-utilization, and lead training and supervision in 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 appropriate, client organizations.
• Consult with psychiatrists and other practitioners about complex patient care through peer review and educational interventions.
• Identify and promptly follow up on quality-of-care concerns with practitioners, 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 in collaboration with the clinical lead senior medical director and quality improvement staff.
• Support the senior medical director in designing and implementing medical action plans and in parity analyses and documentation.
• Participate in committees, project teams, and Joint Operations Committee work as directed.
• 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 as needed to meet deliverables.
• Perform other duties as assigned.

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 wellbeing.

What This Job Offers

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