Medical Director – BH, UM

This is a fully remote position, open to applicants in Hawaii.

📋 Description

• Assist in realizing the clinical vision for health plans encompassing Medicaid, Medicare, and Commercial business segments

• Execute clinical programs that align with the health plan's vision

• Provide clinical guidance and physician oversight to interdisciplinary Medical Management and Utilization Management teams

• Offer consultation and training to care managers regarding care cost and quality

• Engage in case management for high-risk cases and make determinations regarding medical necessity

• Monitor high-risk cases across various care settings, including inpatient, rehabilitation, partial hospitalization, outpatient, and more

• Ensure coordinated care that is medically necessary for individuals with severe, complex, or treatment-resistant conditions

• Design and implement Utilization Management programs and action strategies

• Assess UM practices and criteria while overseeing instances of over- and under-utilization

• Spearhead knowledge sharing, implementation, training, and supervision of medical necessity criteria

• Establish clinical practice standards and policies

• Formulate, execute, and clarify medical policies, technology assessments, and guidelines for medical necessity

• Cultivate relationships with practitioners, healthcare facilities, treatment programs, and client organizations

• Conduct peer reviews and educational initiatives with psychiatrists and other healthcare practitioners

• Address concerns regarding quality of care and ensure compliance with contracts, accreditation, state, and federal regulations

• Promote ongoing quality improvement and adherence to utilization and case management standards

• Engage in both internal and external appeals processes

• Investigate adverse incidents and concerns related to quality of care

• Prepare for NCQA and URAC certification processes

• Lead activities aimed at improving clinical quality in compliance with NCQA standards

• Participate in committees, project teams, and Joint Operations Committee initiatives

• Support the senior medical director with the development of medical action plans and parity analyses

• Maintain licensure requirements for other states as assigned

• Provide after-hours coverage and fulfill health plan and Magellan deliverables outside standard business hours

• Perform additional duties as assigned

⛳️ Requirements

• Targeted specialties include Psychiatry, Psychiatric sub-specialty, Primary Care, Geriatrics, Palliative Care, or Physical Medicine

• A Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), or an equivalent international MBBS degree is required

• International MBBS candidates must successfully complete an internship and residency based in the United States, along with a fellowship for subspecialists

• Successful completion of the ECFMG and FLEX examinations is mandatory

• Full training in a residency program in the United States or Canada accredited by ACGME is essential

• A minimum of three years of post-residency experience with significant direct patient care across multiple care levels

• Relevant clinical experience for the managed patient populations is required

• Must possess an unrestricted, current, and valid license or certification to practice medicine in a U.S. state or territory

• Board certification by ABMS or a relevant specialty board is necessary

• Must demonstrate the ability and willingness to lead and implement necessary changes

• Experience in cost-benefit analysis, medical decision-making processes, credentialing, quality assurance, and continuous quality improvement is required

• Active licensure in Hawaii is mandatory

• After-hours coverage may be necessary

🏝️ Benefits

• Short-term incentives may be available

• Comprehensive benefits package

• Health benefits

• Life benefits

• Voluntary benefits

• Benefits and perks that promote physical, mental, emotional, and financial wellbeing

• Tobacco-free workplace