Massachusetts, New York
Job DescriptionProvides clinical leadership and physician consultation to utilization management, case management, and quality management programs (including Long-Term Supports and Services). Supports the implementation and oversight of medical necessity review function, conducts reviews of clinical cases, and oversees benefit determinations. Works closely with the VP of Health Services, health plan leadership teams, and National Medical Directors to develop and implement medical program policies and procedures.
- 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.
- Ensure all UM programs and policies are in line with industry standards and best practices.
General Job Information
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date5/6/2019
Date Requisition Created5/6/2019
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
- Doctorate Degree in Medicine (MD or DO). If Physical Health Medical Director, must have Current Board Certification in Internal Medicine or Family Medicine If Behavioral Health Medical Director, must have Board Certification in General Psychiatry. Active and unrestricted State Medical License, free of sanctions from Medicaid or Medicare.
- 2+ years’ experience as a Medical Reviewer.
- 2+ years’ experience in Utilization/Case Management and/or Quality Program Management.
- 3+ years’ experience providing direct patient care or 3+ years’ experience working in a behavioral health clinical setting.
- 3+ years of managed care or similar experience.
- Experience demonstrating strong management and communication skills, consensus building and collaborative ability.
- Knowledge of applicable state, federal and third-party regulations.
- Knowledge of NCQA, HEDIS, Medicaid and Medicare managed care preferred.
- Experience treating or managing care for a culturally diverse population preferred.
- Graduate degree in public health or business administration preferred.
- For Behavioral Health Medical Director, training in public health psychiatry preferred.
- For Behavioral Health Medical Director, certification in addiction medicine or in the sub-specialty of addition psychiatry preferred.
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.”