This position supports the clinical vision for Magellan Rx Medicare Basic (PDP) and health plan client(s) within Magellan Rx and implements programs to support this vision. This role works collaboratively with the VP Medical Affairs of Magellan Rx to achieve improved growth, financial performance, and clinical quality improvement of the Magellan Rx Medicare Basic (PDP) and health plan clients.
Medicare Part D:
- Completes case review of standard and expedited redetermination appeals for the Medicare Part D Prescription Drug Plan (PDP). Case review will include communication with prescribers to obtain pertinent additional information. Works closely with the clinical pharmacy team in the process of completion of redetermination appeals. Responds to requests for peer to peer discussions at both the coverage determination and redetermination levels of review for the PDP.
- Provides leadership, expertise, oversight and education to the clinical pharmacy team regarding interpretation of the Medicare Part D CMS approved compendia and compliance with Medicare Part D Policies.
- Participates in the post-adjudication process by reviewing favorable Medicare Part D reconsideration decisions from the Independent Review Entity (IRE) and representing the PDP as an expert physician witness for Administrative Law Judge (ALJ) hearings.
- Assists the clinical team with development and implementation of policies and procedures for the PDP. Participates in the continued development and maintenance of the quality program for the PDP.
- Assists with clinical oversight of the Opioid Overutilization Monitoring System.
- May participate in various committees or project teams related to the PDP as directed by the VP Medical Affairs
Complex Case Management/Utilization Management:
- 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, 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 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 Vice-President Medical Affairs.
- Other duties as assigned.
License and Certifications - Required
DO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician, MD - Physician, State Licensure and Board Certified (ABMSor Specialty Board) - Physician
License and Certifications - Preferred
Other Job Requirements
Complex case management experience.
Managed care experience as a provider and a manager of care.
Utilization Review or Physician Advisor experience.
Accreditation experience (NCQA, AAHCC/URAC)., Medicare Part D expertise.
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 5 years involving substantial direct patient care during this period at multiple levels of care.
Unrestricted current and valid license or certification to practice medicine in a state or territory of the United States.