Medical Director – BH, UM

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🌺 Hawaii – Remote

🌺 Hawaii – Remote

💵 $200.3k - $360.5k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Magellan Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

💼 Consulting

🛡️ Insurance

🏥 Healthcare

💰 $101M Private Equity Round on 2004-01

Consulting • Insurance • Healthcare

Magellan Health is a leading healthcare management company that provides a range of services, including behavioral health, pharmacy management, and employee assistance programs. The company focuses on delivering high-quality care and support to individuals and families, particularly those in military and community settings. Magellan Health emphasizes personalized service and innovative solutions to improve health outcomes and enhance the overall patient experience.

📋 Description

• Support the clinical vision for health plans across Medicaid, Medicare, and Commercial lines of business • Implement clinical programs supporting the health plan vision • Provide clinical leadership and medical oversight to the interdisciplinary Medical Management team • Consult with and train care managers to address cost and quality of care • Provide day-to-day physician oversight to an assigned interdisciplinary utilization management team • Participate in case management of at-risk cases and make medical necessity decisions • Follow high-risk cases across inpatient, rehabilitation, partial hospitalization, outpatient, and other treatment levels • Ensure medically necessary coordinated care for people with severe, complex, or treatment-resistant illnesses • Oversee at-risk patients in complex case management and complete utilization management activities • Develop case management plans • Develop and implement utilization management programs and action plans • Evaluate UM practices and criteria and monitor over- and under-utilization • Lead knowledge, implementation, training, and supervision of medical necessity criteria • Implement clinical practice standards and policies • Develop, implement, and interpret medical policy, technology assessments, and medical necessity guidelines • Build relationships with practitioners, provider facilities, treatment programs, and client organizations • Conduct peer review and educational interventions with psychiatrists and other practitioners • Identify and follow up on quality-of-care concerns • Ensure contract requirements, NCQA standards, state policies, and federal policies are implemented • Support continuous quality improvement and compliance in utilization and case management • Participate in internal and external appeals processes • Investigate adverse incidents and quality-of-care concerns • Prepare for NCQA and URAC certifications • Lead NCQA-compliant clinical quality improvement activities • Participate in committees, project teams, and Joint Operations Committee work • Support 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 typical business hours as needed • Perform other duties as assigned

🎯 Requirements

• Active Hawaii licensure required • Targeted specialties: Psychiatry, Psychiatric sub-specialty, Primary Care, Geriatrics, Palliative Care, or Physical Medicine • Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), or international MBBS degree with successful completion of United States-based internship and residency required • Successful completion of ECFMG and FLEX examinations • Full training in a United States- or Canada-based residency program approved by ACGME • At least 3 years of post-residency experience involving substantial direct patient care at multiple levels of care • Clinical experience pertinent to the managed patient populations • Unrestricted current and valid license or certification to practice medicine in a United States state or territory • Ability and desire to lead 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 • Board certification (ABMS or specialty board) listed as required • Compliance with security responsibilities, controls, legal, regulatory, contractual, and internal policy requirements

🏖️ Benefits

• Short-term incentives may be available • Comprehensive benefits package • Health, life, voluntary, and other benefits • Benefits and perks supporting physical, mental, emotional, and financial wellbeing • Tobacco-free workplace

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