National VP, Medical Director Cost of Care Quality & Innovation
Job DescriptionProvides strategic direction, clinical oversight and leadership for the Magellan Complete Care (MCC) medical policy, utilization management, cost of care initiatives and patient safety programs for all products, benefits and services the organization administers for state and federal customers. Accountable to ensure that MCC’s national medical policies, in development, implementation and governance, reflect evidenced based guidelines, national best practice, state and federal guidelines and adhere to all accreditation parameters as necessary and appropriate. Manages the governance and oversight of the administration of medical policy, directly oversees the utilization management organization (including direct management and oversight of the physicians performing utilization management) and oversees the multidisciplinary governance processes that determine the appropriate execution and implementation of policy and medical necessity determinations. Works with analytics, actuarial and medical economics resources to develop and execute a cost of care strategy that furthers the goal of achieving affordability initiatives, driving value over volume and ensuring that the market health plans can achieve margin sustainability for long term growth. This is inclusive of scoping complex opportunities that have impact on clinical, operational and network performance, and driving to the appropriate tools and metrics to measure achievement of established goals. The work product and thought leadership of this VP also influences network strategy, operational execution and payment integrity efforts. Reports to the Magellan Complete Care chief medical officer. Collaborates with and relates to internal stakeholders across the organization including, but not limited to, health services, health plan CEOs, network, finance and quality/provider performance leadership.
• Develops and implements medical policy for all benefits and services that ensure member safety, reduce unwarranted variation and ensure MCC upholds the highest level of rigor in the application of utilization management standards.
• Develops and implements a national, standardized utilization management program based upon industry best practices, ensuring compliance with regulatory, state, corporate and accreditation requirements. Oversees utilization determinations.
• Provides clinical/medical leadership and expertise for utilization management cost containment and quality improvement activities. Evaluates the effectiveness of utilization management programs and modifies programs as needed to achieve desired results.
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
• Develops medical cost affordability initiatives and ensures that those initiatives are measured, monitored and executed on in alignment with health plan goals and budgets.
• Monitors all local market utilization management program activities for quality compliance according to NCQA and CMS standards.
• Allocates medical resources to meet the utilization review needs of all markets, including contracting with external organizations to improve the scale and effectiveness of the organization as appropriate, with appropriate oversight accountability as necessary
• Participates in provider network development strategies and contracting efforts, as well as new market expansion, including RFP responses, as appropriate.
• Collaborates with other Magellan portfolio companies to align best practices, particularly when MCC is utilizing services purchased from another Magellan company.
• 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.
• Provides input to policies and procedures for utilization and case management.
• Implements and follows clinical practice guidelines and medical necessity review criteria.
• Ensures all UM programs and policies are in line with industry standards and best practices.
General Job Information
TitleNational VP, Medical Director Cost of Care Quality & Innovation
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date8/29/2019
Date Requisition Created8/29/2019
Work ExperienceManaged Healthcare, Medical, Medicare, Utilization Management
EducationDO (Required), Masters: Business Administration, Masters: Public Health, MD (Required)
License and Certifications - RequiredDO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician
License and Certifications - PreferredMD - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician
Other Job Requirements
• 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
• Board Certification in Internal Medicine or Family Medicine preferred
• Doctorate Degree in Medicine (MD or DO)
• 7+ years’ experience as a Medical Director in managed care
• 10+ years’ experience in Utilization Management
• 5+ years’ leadership experience, preferably in a managed care environment
• Experience demonstrating strong management and communication skills, consensus building and collaborative ability.
• Knowledge of applicable state, federal and third-party regulations
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.”