Clinical - Medical Director - 210034

Job Profile Summary Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.Education & Experience Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred.State‑specific requirementsBehavioral Health only: Board certification by the American Board of Psychiatry and Neurology. Current state medical license without restrictions.Buckeye Community Health Plan: Board certification in general psychiatry or child psychiatry, 5+ years in behavioral health managed care or clinical settings, at least 2 years in a clinical setting. Certification in addiction medicine or addiction psychiatry preferred.NV Substance Abuse Disorder Physician Only: Board Certification through American Board Medical Specialties, certification in addiction medicine or addiction psychiatry. Current state medical license without restrictions.NV only: Board Eligible physician. Must obtain Board Certification within reasonable time frame.Oklahoma Specialty Children’s Plan: Board certified and currently licensed in Oklahoma as a child psychiatrist.Illinois plan: Must reside in Illinois and have at least eight (8) years of experience in mental health, substance abuse, or child services. Will be responsible for all Behavioral Health activities.MHS Indiana: Indiana‑licensed Geriatrician assisting the Chief Medical Director with utilization management, care management, and quality departments.DE Only (Behavioral Health): Psychiatrist or board certified Psychiatric Mental Health Nurse Practitioner or Clinical Nurse Specialist with an Advanced Practice Nursing license in Delaware, at least five years combined experience in mental health and substance use services.DE LTSS Only: Board certified physician with experience in long‑term services and supports.License & Certifications Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services. Certification in Psychiatry is required. Current state license as MD or DO without restrictions, limitations, or sanctions.Responsibilities Provide medical leadership of utilization management, cost containment, and medical quality improvement activities.Perform medical review activities for utilization review, quality assurance, and complex or experimental medical services.Support implementation of performance improvement initiatives for capitated providers.Assist the Chief Medical Director in planning and establishing goals and policies to improve quality and cost‑effectiveness of care.Provide medical expertise in approved quality improvement and utilization management programs.Assist with functioning of physician committees.Conduct regular rounds to assess and coordinate care for high‑risk patients.Collaborate with clinical teams, network providers, appeals team, medical and pharmacy consultants on complex cases and medical necessity appeals.Participate in provider network development and new market expansion as appropriate.Assist in physician education with respect to clinical issues and policies.Identify utilization review studies and evaluate adverse trends in utilization and provider practice patterns.Identify clinical quality improvement studies to reduce unwarranted variation in practice.Interface with physicians and other providers to implement recommendations that improve utilization and quality.Review claims involving complex or new services to determine medical necessity and payment.Develop alliances with the provider community through medical management programs.Represent the business unit before local and national publics on medical philosophy and policies.Represent the business unit at state and ad‑hoc committees.Work weekends and holidays in support of business operations as needed.For NH Substance Use Disorder Physician Provide clinical oversight and guidance for the MCO on substance use disorder issues, including evidence‑based assessments, treatment protocols, MAT, engagement with PRSS, and discharge planning for members with ED or hospital visits for overdose. Consult on MCO clinical policy related to substance use disorder and MCM program cases. Perform other duties as assigned. Comply with all policies and standards.EEO Statement “Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”Story Behind the Need – Business Group & Key Projects Health plan or business unitTeam cultureSurrounding team & key projectsPurpose of this teamReason for the requestMotivators for this needAny additional upcoming hiring needs?Medicare Line of Business. Business Unit: Medicare Product Team.Team Culture: Collaborative, Team player.We work closely with our PHCO and CM partners.Purpose of our team: We are the Medicare Inpatient Pod and specialize in doing Inpatient Concurrent, Post‑Acute Care reviews and well as Pre‑service and par retro/claims appeals for Inpatient and post‑acute care stays.Large volume of IP/Client cases. Currently short staffed.Typical Day in the Role Daily schedule & OT expectationsTypical task breakdown and rhythmInteraction level with teamWork environment descriptionTypically 8‑5 pm local time, sometimes beyond 5 pm if day’s work is not done.We work on 3 different platforms to get the work done.We are constantly interacting with team members via Teams to assist each other.We reach out to each other when we can help or when we need a hand.Compelling Story & Candidate Value Proposition What makes this role interesting?Points about team cultureCompetitive market comparisonUnique selling pointsValue added or experience gainedWe get to help our members with discharge needs, move them to the appropriate level of care, and provide resources to avoid readmissions and transition home with needed DME/services.The team is hardworking, collaborative, and always willing to help each other.Candidate Requirements Education/Certification Required: Active Board Certification in Internal Medicine or Family Medicine.Preferred: —Licensure Required: FL, TX.Preferred: AZ, DE, IA, SC, OH, IL, MI.Years of Experience Must have Medicare UM experience, IQ/MCG experience.Disqualifiers No active board certification or inpatient clinical experience.Performance Indicators Audit pass score >90%.Productivity >45 cases per day.Top Must‑Have Hard Skills Medicare UM experienceKnowledge about Interqual and MCGTeam player, hard worker, collaborative#J-18808-Ljbffr