Senior Medical Director, Behavioral Health - New Mexico at Magellan Health Services inc in Albuquerque, New Mexico

Job Description:

This position supports the clinical vision for the health plan(s) for all lines of business (Medicaid, Medicare and Commercial) and implements and manages programs to support this vision. The Senior Medical Director ensures the delivery of appropriate health care by overseeing the service coordination, utilization management, care/case management, population health/disease management, cost of care, health promotion, quality improvement programs, and the medical action plans for the assigned business unit and/or designated health plans within a national region. Leads parity efforts and maintains parity documentation and updates with updates in clinical and medical management. Ensures the medical policies, clinical guidelines, quality and clinical operations policies of the company are consistently implemented and NCQA and/or URAC compliant. Analyzes utilization, quality, and financial data to ensure high quality and cost-effective delivery of care. Monitors and oversees the work of the Medical Directors and Physician Advisors in providing cost-effective and quality care management services. Also develops and sustains an interface with providers, health plan partners and members, state agencies, and promotes the image and clinical excellence model of the company in the community and with key stakeholders. Maintains process and outcome reporting for all functions listed above. This leadership role will often require working outside normal business hours and may require travel for client meetings.

• Provides clinical leadership to the interdisciplinary Medical Management team, which includes clinical/medical oversight of clinical team members and consultation and training with care managers in order to address cost and quality of care. Provides day to day physician oversight to an assigned interdisciplinary UM team.


• Responsible for the quality of utilization review determinations, including appeals.


• Reviews cases, makes medical necessity determinations, and conducts peer to peer reviews.


• Ensures compliance with case management and disease management programs and clinical goals through regular monitoring of case management center performance.


• Participates in case rounds and development of case management plans for individual members.


• Evaluates the effectiveness and cost of care of clinical programs through review and analysis of utilization and financial data., Assists with root cause analyses and enterprise resolution of issues; modifies programs as needed to achieve desired results.


• Provides an interface and has accountability and responsibility to handle external stakeholders, including key health plan and state government partners through outreach to customer medical directors and state or federal agencies and regulators. Attends standing meetings as needed to discuss emerging issues, improvement in metrics, and strategic plans. Delivers Magellan approved public and stakeholder presentations.


• Provides medical leadership, oversight, and consultation for Quality Improvement (QI) Programs including monitoring effectiveness and compliance with goals, prevention programs, network development and management, quality of care concerns and adverse incidents, medical practice of network or sub-capitated providers, clinical service delivery system, coordination with After Hours Team, and oversight of clinical appeals.


• Provides documentation to support medical management decision making with regard to all elements related to parity; interfaces with health plan and client leaders on parity discussions.


• Chairs and/or participates in the Regional Network Credentialing Committee (RNCC) and the Quality Improvement Committee (QIC). Develops and provides leadership for NCQA compliant clinical quality improvement activity (QIA) in collaboration with key stakeholders. Participates in QI projects.


• Recruits, trains, supervises, mentors, oversees and evaluates the quality of medical staff and physician advisors. Ensures adequate physician resources. Develops and manages medical director and physician advisor budgets, travel budgets, and continuing medical education budgets.


• Develops and implements the Medical Action Plan (MAP) to address the cost of care for all health plans overseen by the assigned position which includes metrics for utilization and quality management. Develops mitigating strategies to ensure goals are met or exceeded. Works closely with the clinical care management to ensure effective staff case review.


• Responsible for implementing Magellan and national and local medical policies/procedures. Provides input regarding the need for modifications and additions to medical policy. May participate on corporate medical policy and clinical guideline committees. May do background research to support clinical decision making and policies.


• Assesses technology and clinical practice standards developed by the company and participates in management of the inter-rater reliability process to ensure consistency between reviewers.


• Monitors quality and quantity of clinical reviews and care plans. Works closely with the network management team on an integrated clinical-network approach which may include provider relationships. Visits providers and attends joint operating committee meetings with health plans.


• Provides after-hours coverage as required.


• Maintains licensure requirements as per Magellan policies.


• Meets with CMO to review results on initiatives as described above.


• Maintains licenses in states being served within the respective lines of business in order to provide support for other medical directors.


• Participates in RFP response development and writing.


• Other duties as assigned.

Responsibilities
Targeted specialties are Psychiatry, Psychiatric sub-specialty, Primary Care, Geriatrics, Palliative Care or Physical Medicine.
Doctor of Medicine (MD) degree OR Doctor of Osteopathic Medicine (DO) degree OR Bachelor of Medicine, Bachelor of Surgery (MBBS) international degree with successful completion of United States based internship and residency (and successful completion of United States based fellowship for subspecialists) required.
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).
Post-residency experience of at least 7 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 to lead through and effect appropriate changes.
Experience with cost-benefit analysis, medical decision analysis, credentialing, quality assurance and continuous quality improvement (CQI) processes.

General Job Information

Title
Senior Medical Director, Behavioral Health - New Mexico

Grade
37

Work Experience - Required
Clinical

Work Experience - Preferred

Education - Required
DO, MBBS, MD

Education - Preferred

License and Certifications - Required
DO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician, MBBS - Bachelor of Medicine, Bachelor of Surgery - Physician, MD - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician

License and Certifications - Preferred

Salary Range

Salary Minimum:
$222,380
Salary Maximum:
$422,520

This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.

This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.

Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.