Provides day to day physician oversight to an assigned interdisciplinary UM team, including regular involvement in the 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 that 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.
Evaluates the effectiveness of UM practices and criteria. Actively monitors for over- and under-utilization. Assumes a leadership position relative to knowledge, implementation, training and supervision of the use of the medical necessity criteria.
Develops, implements and interprets medical policy, technology assessments, and medical necessity guidelines.
Confers directly with psychiatrists and other practitioners regarding the 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 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 preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the 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.
Other Job Requirements
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.