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 sectors.

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

• Provide clinical leadership and medical oversight for the interdisciplinary Medical Management team.

• Consult and train care managers to enhance cost and quality of care.

• Offer daily physician oversight to an assigned interdisciplinary utilization management team.

• Engage in case management for at-risk patients and make determinations regarding medical necessity.

• Monitor high-risk cases across inpatient, rehabilitation, partial hospitalization, outpatient, and other care levels.

• Guarantee medically necessary coordinated care for individuals with severe, complex, or treatment-resistant conditions.

• Supervise at-risk patients in complex case management and execute utilization management tasks.

• Formulate case management plans.

• Design and implement utilization management programs and action plans.

• Assess UM practices and criteria while monitoring for over- and under-utilization.

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

• Enforce clinical practice standards and policies.

• Develop, execute, and clarify medical policy, technology assessments, and medical necessity guidelines.

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

• Carry out peer reviews and educational interventions with psychiatrists and other healthcare professionals.

• Recognize and address quality-of-care issues.

• Ensure the implementation of contract requirements, NCQA standards, state regulations, and federal policies.

• Promote continuous quality improvement and compliance in utilization and case management.

• Engage in internal and external appeals processes.

• Investigate adverse incidents and quality-of-care concerns.

• Prepare for NCQA and URAC certifications.

• Lead clinical quality improvement initiatives that comply with NCQA standards.

• Participate in committees, project teams, and Joint Operations Committee activities.

• Assist the senior medical director with medical action plans, parity analyses, and documentation.

• Maintain licensure requirements for other states as assigned.

• Provide after-hours coverage and work beyond standard business hours as required.

• Perform additional duties as assigned.

⛳️ Requirements

• Active Hawaii licensure is required.

• 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 international MBBS degree with successful completion of a United States-based internship and residency is required.

• Successful completion of ECFMG and FLEX examinations is necessary.

• Full training in a residency program in the United States or Canada that is approved by ACGME is required.

• A minimum of 3 years of post-residency experience involving significant direct patient care at various levels of care is essential.

• Clinical experience relevant to the managed patient populations is crucial.

• An unrestricted and valid license or certification to practice medicine in a U.S. state or territory is mandatory.

• A strong ability and willingness to lead and implement necessary changes is necessary.

• Experience with cost-benefit analysis, medical decision-making analysis, credentialing, quality assurance, and continuous quality improvement (CQI) processes is preferred.

• After-hours coverage may be required.

• Board certification (ABMS or specialty board) is required.

• Compliance with security responsibilities, controls, legal, regulatory, contractual, and internal policy requirements is essential.

🏝️ Benefits

• Short-term incentives may be available.

• Comprehensive benefits package.

• Health, life, voluntary, and additional benefits.

• Benefits and perks that support physical, mental, emotional, and financial well-being.

• Tobacco-free workplace.