- 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, including regular involvement in the case management of at-risk cases and medical necessity decisions. Follows high risk cases throughout treatment continuum from inpatient, rehabilitation, partial hospitalization, outpatient and other levels of care. Ensures that persons with severe, complex, and/or treatment resistant illnesses receive medically necessary coordinated care throughout the episode of treatment. Continues physician oversight of at-risk patients deemed appropriate for complex case management and timely completion of all utilization management activities. Involvement in the development of case management plans.
- Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most cost-effective setting. Evaluates the effectiveness of UM practices and criteria. Actively monitors for over- and under-utilization. Assumes a leadership position relative to knowledge, implementation, training and supervision of the use of the medical necessity criteria.
- Along with the Corporate Clinical team, implements clinical practice standards and policies developed by Magellan corporate and participates in management of activities. Develops, implements and interprets medical policy, technology assessments, and medical necessity guidelines.
- Develops effective working relationships with practitioners, provider facilities, treatment programs, and may establish relationships and/or consult with client organizations. Confers directly with psychiatrists and other practitioners regarding the care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions. Identifies and immediately follows up any quality of care concerns with practitioners and provider facilities and treatment programs involved in the member's care. Ensures that contract requirements, accreditation standards (e.g. NCQA), state policies and federal policies are implemented specific to each Magellan client. Works with teams on continuous quality improvement to ensure ongoing compliance in utilization and case management.
- Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead senior medical director, and quality improvement staff. May participate in various committees or project teams as directed by the senior medical director or vice-president.
- Supports senior medical director in designing and implementing medical action plans.
- Supports senior medical director in parity analyses and documentation.
- Participates in committee work and JOC (Joint Operations Committee).
- Maintains licensure requirements for other states as assigned by senior medical director and CMO.
- Provides after hours coverage.
- May need to work beyond typical business hours to meet health plan and Magellan deliverables.
- Other duties as assigned.
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Medical Director, Children in State Custody - Albuquerque, United States - Magellan Health Services
Description
This position has special interest in working with a broad range of mental health conditions in children with special emphasis on trauma spectrum disorders.
Has solid knowledge and experience in working with the child welfare system.Is a subject matter expert in resources available to CISC children and youth in need of behavioral, physical and long-term care supports.
Is knowledgeable of the resources available to CISC Members within the communities at the state and local level.Utilize this understanding of the Behavioral Health System of Care to support transitions of care including continuation of services with non-contracted providers, tribal and community partners.
This position will require a clinical leader to incorporate and serve multiple stakeholders in a system of care for youth in New Mexico.
This position supports the clinical vision for the health plan(s) for all lines of business (Medicaid, Medicare, and Commercial) and implements programs to support this vision.
Responsibilities
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.
Full training in a residency program in the United States or Canada that is approved by the Accreditation Council for Graduate Medical Education (ACGME).
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. (Preferred, but not required for MRx MMUM).
After Hours coverage may be required.
General Job Information
Title
Medical Director, Children in State Custody (NM Licensed, Child Psychiatrist)
Grade
36
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:
$200,280
Salary Maximum:
$360,500
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.
