Medical Director, Behavioral Health
Richmond VA 23233
Job DescriptionThe Medical Director of Behavioral Health provides clinical leadership and physician consultation to utilization management, case management, care coordination, and peer-support programs. She/he supports the design, implementation, and oversight of integrated behavioral health care management. The Medical Director of Behavioral Health works closely with the VP of Behavioral Health, health plan leadership teams, National Medical Directors to develop and implement policies and procedures and assists the Chief Medical Officer to direct and coordinate the medical management, quality improvement, and credentialing functions.
- Serves as physician advisor for utilization management, cost containment, and quality improvement activities.
- Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services including LTSS initial reviews and appeal reviews of denial determinations made by other reviewers.
- Assists in the planning and establishing of goals and policies to improve quality and cost-effectiveness for plan membership.
- Participates in the development of state and corporate long-term services and supports clinical standards, best practice guidelines and clinical policy to improve member care.
- Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Monitors all utilization management program activities for quality compliance according to NCQA and CMS standards.
- Participates in physician committees including committee structure, processes, and membership. Represents the health plan at appropriate state and other ad hoc committees.
- Participates in provider network development and new market expansion, including RFP responses, as appropriate.
- Assists in the development and implementation of physician education regarding clinical issues and policies. Develops and provides teachings on effective utilization management processes and outcomes.
- Works directly with physicians and providers to implement recommendations to improve utilization and health care quality.
- Partners with the provider community to develop and implement medical management programs.
- Provides input to policies and procedures for utilization and case management.
- Supports the Pharmacy team with the pharmacy appeal review process.
- Implement and follow clinical practice guidelines and medical necessity review criteria.
General Job Information
TitleMedical Director, Behavioral Health
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date4/12/2019
Date Requisition Created4/12/2019
EducationDO (Required), MD (Required)
License and Certifications - RequiredDO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician, MD - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician
License and Certifications - Preferred
Other Job Requirements
- Graduate of an American or Canadian medical school accredited by the Accreditation Council for Medical Education (ACME) or equivalent training in a foreign medical school with 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).
- Minimum of three 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.
Managed care experience as a provider and a manager of care.
Utilization Review or Physician Advisor experience.
Complex case management experience.
Accreditation experience (NCQA, AAHCC/URAC).
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
“I receive a high level of support from our Senior Management Team to execute on our vision. They are always accessible and approachable, something I’ve found to be very unique to Magellan.”