ESSENTIAL FUNCTIONS: * Provides clinical leadership to the interdisciplinary MagellanRx Medical Pharmacy Utilization Management - Clinical Operations team, which includes clinical/medical. Provides day to day physician reviews for medical necessity for various clients across multiple lines of business. This includes (but may not be limited to) peer to peer discussions, medical necessity determinations, and physician consults in a specified timeframe. * Provides clinical support to the Clinical Operations team in preparation for internal and external clinical audits to improve overall quality of the program as needed * Supports and provides clinical feedback to VP, Medical Affairs, Clinical Operations, and Quality Leadership for NCQA and URAC accreditation * Development of annual Inter-Rater Reliability (IRR) assessment for all clinical decision makers including pharmacists and physicians * Provides clinical support to VP, Medical Affairs, Clinical Operations, and Quality team on quarterly Clinical Pharmacist Review and Physician appeal reviews. * 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. * Recruitment and training support of Physician Clinical Reviewers * Obtain licensure in strategic states in which MagellanRx Medical Pharmacy Utilization Management does business * Other duties as assigned.
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).
Minimum of three years involving substantial direct patient care during this period at multiple levels of care.
Clinical experience pertinent to the patient population(s) being managed.
Current board certification in one or more specialties (Hematology/Oncology preferred)
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.
After Hours coverage may be required.
Managed care experience as a provider and a manager of care.
Utilization Review or Physician Advisor experience.
Accreditation experience (NCQA, AAHCC/URAC).
General Job Information
Associate Medical Director
United States of America
United States of America (Exempt)
Recruiting Start Date
Date Requisition Created
License and Certifications - Required
DO - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician, MD - Physician, State Licensure and Board Certified (ABMS or Specialty Board) - Physician
License and Certifications - Preferred
Other Job Requirements
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled