Medical Director (BH, UM) - Honolulu, HI

Job Description

ATTENTION MILITARY AFFILIATED JOB SEEKERS - Our organization works with partner companies to source qualified talent for their open roles. The following position is available to Veterans, Transitioning Military, National Guard and Reserve Members, Military Spouses, Wounded Warriors, and their Caregivers. If you have the required skill set, education requirements, and experience, please click the submit button and follow the next steps. Unless specifically stated otherwise, this role is "On-Site" at the location detailed in the job post.

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, which includes clinical/medical oversight of clinical team members and consultation and training with care managers in order to address cost and quality of care. Provides day to day physician oversight to an assigned interdisciplinary UM team, including regular involvement in the case management of at-risk cases and medical necessity decisions. Follows high risk cases throughout treatment continuum from inpatient, rehabilitation, partial hospitalization, outpatient and other levels of care. Ensures that persons with severe, complex, and/or treatment resistant illnesses receive medically necessary coordinated care throughout the episode of treatment. Continues physician oversight of at-risk patients deemed appropriate for complex case management and timely completion of all utilization management activities. Involvement in the development of case management plans.

Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most cost-effective setting. Evaluates the effectiveness of UM practices and criteria. Actively monitors for over- and under-utilization. Assumes a leadership position relative to knowledge, implementation, training and supervision of the use of the medical necessity criteria.

Along with the Corporate Clinical team, implements clinical practice standards and policies developed by Magellan corporate and participates in management of activities. Develops, implements and interprets medical policy, technology assessments, and medical necessity guidelines.

Develops effective working relationships with practitioners, provider facilities, treatment programs, and may establish relationships and/or consult with client organizations. Confers directly with psychiatrists and other practitioners regarding the care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions. Identifies and immediately follows up any quality of care concerns with practitioners and provider facilities and treatment programs involved in the member’s care. Ensures that contract requirements, accreditation standards (e.g. NCQA), state policies and federal policies are implemented specific to each Magellan client. Works with teams on continuous quality improvement to ensure ongoing compliance in utilization and case management.

Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of 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) in collaboration with the clinical lead senior medical director, and quality improvement staff. May participate in various committees or project teams as directed by the senior medical director or vice‑president.

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 by senior medical director and CMO.

Provides after hours coverage.

May need to work beyond typical business hours to meet health plan and Magellan deliverables.

Other duties as assigned.

The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description.

Other Job Requirements

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 (and successful completion of United States based fellowship for subspecialists) required.

Successful completion of the ECFMG and FLEX examinations.

Full training in a residency program in the United States or Canada that is approved by the Accreditation Council for Graduate Medical Education (ACGME).

Post‑residency experience of at least 3 years involving substantial direct patient care during this period at multiple levels of 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.

After Hours coverage may be required.

Bachelors

General Job Information

Title

Medical Director (BH, UM) Remote HI

Grade

36

Work Experience - Required

Clinical