This position is remote in New Mexico; candidates must be NM licensed and reside in NM.
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. This leadership role will often require working outside normal business hours and may require travel for client meetings.
Key Responsibilities
- Provides clinical leadership to the interdisciplinary Medical Management team, including clinical/medical oversight of clinical team members and consultation and training with care managers.
- 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 modifies programs as needed.
- Provides an interface and is accountable to handle external stakeholders, including key health plan and state government partners.
- Provides medical leadership, oversight, and consultation for Quality Improvement (QI) Programs.
- Provides documentation to support medical management decision-making regarding parity.
- Chairs and/or participates in the Regional Network Credentialing Committee (RNCC) and the Quality Improvement Committee (QIC).
- Recruits, trains, supervises, mentors, and evaluates the quality of medical staff and physician advisors.
- Develops and implements the Medical Action Plan (MAP) to address the cost of care for all health plans overseen.
- Responsible for implementing Magellan and national and local medical policies/procedures.
- Assesses technology and clinical practice standards developed by the company.
- Monitors quality and quantity of clinical reviews and care plans.
- Provides after-hours coverage as required.
- Maintains licensure requirements as per Magellan policies.
- Meets with CMO to review results on initiatives.
- Maintains licenses in states being served.
- Participates in RFP response development and writing.
- Other duties as assigned.
Minimum Requirements
Targeted Specialties: Psychiatry, Psychiatric sub-specialty, Primary Care, Geriatrics, Palliative Care, or Physical Medicine.
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree or equivalent international degree.
- Graduate of an accredited American or Canadian medical school.
- Full training in a residency program in the United States or Canada.
- Post-residency experience of at least 7 years involving substantial direct patient care.
- 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 and quality assurance processes.
General Job Information
Title: Senior Medical Director, Behavioral Health - New Mexico
Grade: 37
Work Experience - Required: Clinical
Work Experience - Preferred: N/A
Education - Required: DO, MBBS, MD
License and Certifications - Required: DO, MBBS, MD - State Licensure and Board Certified.
Salary Range: $222,380 - $422,520
This information reflects the anticipated base salary range for this position based on current national data. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
