Job DescriptionPrimary responsibility is to make independent medical necessity and appropriateness decisions and to provide independent medical consultation to Magellan medical and care management staff.
- Provides independent peer review activity function, including review for medical necessity, level of care, quality, and appropriateness of care.
- Provide clinical rationale for all initial decisions as well as standard and expedited appeals.
- Reviews are performed by speaking directly with clinicians and/or by reviewing clinical records.
- Provides peer-to-peer discussions with ordering providers and their staff when requested as well as guidance and education on guidelines to improve the quality of future requests.
- Performs second level of review for second opinions and appeals as requested.
- Documents all communication with medical office staff and/or physician provider in a timely and accurate manner.
- Offers expert consultation and advice to formal committees as recommended by the Medical Director.
General Job Information
TitleMedical Director/Physician Advisor
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date8/19/2019
Date Requisition Created8/19/2019
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
- Must hold current, active license to practice medicine in the United States.
- Licensure must be for independent practice and be unencumbered by sanctions, practice restrictions or other disciplinary actions.
- Must hold licensure or be license eligible in state of operation.
- Licensure must be complete within the 1st year of employment.
- In addition, hold an active license to practice medicine in the state where required to conduct utilization review activities, if required for the position.
- Must be board-certified in a medical specialty by the American Board of Medical Specialties (ABMS) or by a specialty affiliate of the American Osteopathic Association (AOA).
- Post-residency experience of at least 5 years involving substantial direct patient care during this period at multiple levels of care.
- 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 ACGME.
Managed care experience as a provider and a manager of care. Utilization Review or Physician Advisor experience preferred. Accreditation experience (NCQA, AAHCC/URAC) 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.”