Magellan Health

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.
• • Provides day to day physician oversight to an assigned interdisciplinary UM team, including involvement in case management of at-risk cases and medical necessity decisions.
• • Follows high risk cases throughout treatment continuum from inpatient, rehabilitation, partial hospitalization, outpatient and other levels of care.
• • Ensures persons with severe, complex, and/or treatment resistant illnesses receive medically necessary coordinated care throughout the episode of treatment.
• • Continues physician oversight of at-risk patients deemed appropriate for complex case management and timely completion of all utilization management activities.
• • Involvement in the development of case management plans.
• • Develops and implements a Utilization Management program and action plan, including strategies to ensure high quality patient care and cost-effective settings.
• • Evaluates the effectiveness of UM practices and criteria, actively monitors for over- and under-utilization.
• • Assumes leadership in knowledge, implementation, training and supervision of medical necessity criteria.
• • Implements clinical practice standards and policies developed by Magellan corporate and participates in management of activities.
• • Develops, implements and interprets medical policy, technology assessments, and medical necessity guidelines.
• • Develops effective working relationships with practitioners, provider facilities, treatment programs, and consults with client organizations.
• • Confers directly with psychiatrists and other practitioners regarding care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions.
• • Identifies and immediately follows up any quality of care concerns with practitioners and provider facilities and treatment programs involved in the member’s care.
• • Ensures 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.
• • Responsible for investigation of adverse incidents and quality of care concerns.
• • Participates in preparation for NCQA and URAC certifications.
• • Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with clinical lead senior medical director and quality improvement staff.
• • May participate in various committees or project teams as directed by the senior medical director or vice-president.
• • Supports senior medical director in designing and implementing medical action plans.
• • Supports senior medical director in parity analyses and documentation.
• • Participates in committee work and JOC (Joint Operations Committee).
• • Maintains licensure requirements for other states as assigned by senior medical director and CMO.
• • Provides after hours coverage.
• • May need to work beyond typical business hours to meet health plan and Magellan deliverables.
• • Other duties as assigned.