Medical Director, Behavioral Health
Company: Magellan Health
Posted on: September 19, 2019
The Medical Director of Behavioral Health provides clinical
leadership and physician consultation to utilization management,
case management, care coordination, and peer-support programs.
She/he supports the design, implementation, and oversight of
integrated behavioral health care management. The Medical Director
of Behavioral Health works closely with the VP of Behavioral
Health, health plan leadership teams, National Medical Directors to
develop and implement policies and procedures and assists the Chief
Medical Officer to direct and coordinate the medical management,
quality improvement, and credentialing functions.
- Serves as physician advisor for utilization management, cost
containment, and quality improvement activities.
- Performs medical review activities pertaining to utilization
review, quality assurance, and medical review of complex,
controversial, or experimental medical services including LTSS
initial reviews and appeal reviews of denial determinations made by
- Assists in the planning and establishing of goals and policies
to improve quality and cost-effectiveness for plan membership.
- Participates in the development of state and corporate
long-term services and supports clinical standards, best practice
guidelines and clinical policy to improve member care.
- Provides medical expertise in the operation of approved quality
improvement and utilization management programs in accordance with
regulatory, state, corporate, and accreditation requirements.
Monitors all utilization management program activities for quality
compliance according to NCQA and CMS standards.
- Participates in physician committees including committee
structure, processes, and membership. Represents the health plan at
appropriate state and other ad hoc committees.
- Participates in provider network development and new market
expansion, including RFP responses, as appropriate.
- Assists in the development and implementation of physician
education regarding clinical issues and policies. Develops and
provides teachings on effective utilization management processes
- Works directly with physicians and providers to implement
recommendations to improve utilization and health care
- Partners with the provider community to develop and implement
medical management programs.
- Provides input to policies and procedures for utilization and
- Supports the Pharmacy team with the pharmacy appeal review
- Implement and follow clinical practice guidelines and medical
necessity review criteria.General Job InformationTitleMedical
Director, Behavioral HealthGrade34Job FamilyClinical Services
GroupCountryUnited States of AmericaFLSA StatusUnited States of
America (Exempt)Recruiting Start Date4/12/2019Date Requisition
Created4/12/2019Work 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 RequirementsResponsibilities
- Managed care experience as a provider and a manager of
- Utilization Review or Physician Advisor experience.
- Complex case management experience.--
- Accreditation experience (NCQA, AAHCC/URAC).
- 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)
- Unrestricted current and valid license or certification to
practice medicine in a state or territory of the United
- Ability and desire to lead through and effect appropriate
- Experience with cost-benefit analysis, medical decision
analysis, credentialing, quality assurance and continuous quality
improvement (CQI) processes.
- After Hours coverage may be required.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, Virginia Beach , Medical Director, Behavioral Health, Executive , Richmond, Virginia
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