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 across Medicaid, Medicare, and Commercial lines of business

• Execute clinical programs that align with the health plan vision

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

• Consult with and train care managers on cost and quality of care

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

• Monitor high-risk cases through various levels of care including inpatient, rehabilitation, partial hospitalization, outpatient, and others

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

• Develop and execute Utilization Management programs and action plans

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

• Lead the knowledge dissemination, implementation, training, and supervision of medical necessity criteria

• Enforce clinical practice standards and policies

• Formulate, implement, and interpret medical policies, technology assessments, and medical necessity guidelines

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

• Conduct peer reviews and educational interventions with psychiatrists and other healthcare professionals

• Address quality-of-care issues and ensure adherence to contract, accreditation, state, and federal requirements

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

• Participate in internal and external appeals processes

• Investigate adverse incidents and concerns related to quality of care

• Prepare for NCQA and URAC certifications

• Lead clinical quality improvement initiatives compliant with NCQA standards

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

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

• Maintain licensure requirements for other designated states

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

• Perform additional duties as assigned

⛳️ Requirements

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

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

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

• Successful completion of the ECFMG and FLEX examinations is essential

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

• Minimum of 3 years of post-residency experience that includes substantial direct patient care across multiple levels of care

• Clinical experience relevant to the managed patient populations is necessary

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

• Board certification by ABMS or a specialty board is necessary

• A strong desire and ability to lead and implement appropriate changes

• Experience with cost-benefit analysis, medical decision analysis, credentialing, quality assurance, and continuous quality improvement processes

• Active Hawaii licensure is required

• Availability for after-hours coverage may be required

🏝️ Benefits

• Short-term incentives may be available

• Comprehensive benefits package

• Health benefits

• Life benefits

• Voluntary benefits

• Benefits and perks promoting physical, mental, emotional, and financial well-being

• Tobacco-free workplace