Sr. Medical Director, Physical Health
Company: Magellan Health
Posted on: November 17, 2019
The Sr. Medical Director contributes to the development and
implementation of the clinical mission of Magellan Complete Care
(MCC) of Arizona's health plan which includes the development,
implementation, and evaluation of comprehensive clinical and
medical programs. This position 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 MCC of Arizona's health
plan. The Sr. Medical Director ensures the medical policies,
clinical guidelines, quality and clinical operations policies of
the company are consistently implemented and NCQA and/or URAC
compliant. The Sr. Medical Director analyzes utilization, quality,
and financial data to ensure high quality and cost effective
delivery of care and monitors and oversees the work of the Medical
Directors and Physician Advisors in providing cost-effective and
quality care management services. This position 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
- Assumes overall accountability for utilization management and
case management for MCC of Arizona. 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
- 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
- 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
- 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
- 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.General Job
InformationTitleSr. Medical Director, Physical HealthGrade35Job
FamilyClinical Services GroupCountryUnited States of AmericaFLSA
StatusUnited States of America (Exempt)Recruiting Start
Date7/10/2019Date Requisition Created7/10/2019Work
ExperienceClinicalEducationDO (Required), MD (Required)License and
Certifications - RequiredDO - Physician, State Licensure and Board
Certified (ABMS or Specialty Board) - Physician, MD - Physician,
State Licensure and Board Certified (ABMS or Specialty Board) -
PhysicianLicense and Certifications - PreferredOther Job
- Quality management experience.--
- Accreditation experience (NCQA, AAHCC/URAC).Required
- Doctorate Degree in Medicine (MD or DO). Current Board
Certification in Internal Medicine or Family Medicine.
- Unrestricted current and valid license or certification to
practice medicine in Arizona.
- 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, specifically complex populations, Medicaid and/or
- Managed care experience required as provider and/or manager of
- Utilization Review and Care Management experience.
- 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.Magellan Health Services is proud to be
an Equal Opportunity Employer and a Tobacco-free workplace.
EOE/M/F/Vet/Disabled. Every employee must understand, comply and
attest to the security responsibilities and security controls
unique to their position.
Keywords: Magellan Health, Peoria , Sr. Medical Director, Physical Health, Healthcare , Phoenix, Arizona
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