Contributes to the development and implementation of the clinical mission of an SBU which includes the development, implementation, and evaluation of comprehensive clinical and medical programs. Accountable for a select health plan or small number of plans/clients. 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. 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.
- Assumes overall accountability for utilization management and case management for a select health plan or small number of plans/clients in a region. Develops and implements a utilization management program and oversees the quality of utilization determinations. Provides medical direction to the support services review process. 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.
- Chairs 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.
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
Managed care experience, as a provider and within a managed care organization.
Utilization Review experience.
Case management experience.
Quality management experience.
Accreditation experience (NCQA, AAHCC/URAC)., Targeted specialties are Primary Care, Geriatrics, Palliative Care or Physical Medicine.
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.
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.