Senior Medical Director (CMO), Behavioral Health - New Mexico

This position will serve as CMO for the health plan and is a remote in New Mexico. Candidates must be licensed and reside in NM.

This position supports the clinical vision for the health plan(s) for all lines of business (Medicaid, Medicare and Commercial) and implements and manages programs to support this vision. The Senior Medical Director ensures the delivery of appropriate health care by overseeing the service coordination, utilization management, care/case management, population health/disease management, cost of care, health promotion, quality improvement programs, and the medical action plans for the assigned business unit and/or designated health plans within a national region. Leads parity efforts and maintains parity documentation and updates with updates in clinical and medical management. Ensures the medical policies, clinical guidelines, quality and clinical operations policies of the company are consistently implemented and NCQA and/or URAC compliant. Analyzes utilization, quality, and financial data to ensure high quality and cost-effective delivery of care. Monitors and oversees the work of the Medical Directors and Physician Advisors in providing cost-effective and quality care management services. Also develops and sustains an interface with providers, health plan partners and members, state agencies, and promotes the image and clinical excellence model of the company in the community and with key stakeholders. Maintains process and outcome reporting for all functions listed above. This leadership role will often require working outside normal business hours and may require travel for client meetings.

• Provides clinical leadership to the interdisciplinary Medical Management team, which includes clinical/medical oversight of clinical team members and consultation and training with care managers in order to address cost and quality of care. Provides day to day physician oversight to an assigned interdisciplinary UM team.
• Responsible for the quality of utilization review determinations, including appeals.
• Reviews cases, makes medical necessity determinations, and conducts peer to peer reviews. 
• Ensures compliance with case management and disease management programs and clinical goals through regular monitoring of case management center performance.
• Participates in case rounds and development of case management plans for individual members. 
• Evaluates the effectiveness and cost of care of clinical programs through review and analysis of utilization and financial data., Assists with root cause analyses and enterprise resolution of issues; modifies programs as needed to achieve desired results.
• Provides an interface and has accountability and responsibility to handle external stakeholders, including key health plan and state government partners through outreach to customer medical directors and state or federal agencies and regulators.  Attends standing meetings as needed to discuss emerging issues, improvement in metrics, and strategic plans.  Delivers Magellan approved public and stakeholder presentations.
• Provides medical leadership, oversight, and consultation for Quality Improvement (QI) Programs including monitoring effectiveness and compliance with goals, prevention programs, network development and management, quality of care concerns and adverse incidents, medical practice of network or sub-capitated providers, clinical service delivery system, coordination with After Hours Team, and oversight of clinical appeals.
• Provides documentation to support medical management decision making with regard to all elements related to parity; interfaces with health plan and client leaders on parity discussions.
• Chairs and/or participates in the Regional Network Credentialing Committee (RNCC) and the Quality Improvement Committee (QIC). Develops and provides leadership for NCQA compliant clinical quality improvement activity (QIA) in collaboration with key stakeholders. Participates in QI projects.
• Recruits, trains, supervises, mentors, oversees and evaluates the quality of medical staff and physician advisors. Ensures adequate physician resources. Develops and manages medical director and physician advisor budgets, travel budgets, and continuing medical education budgets.
• Develops and implements the Medical Action Plan (MAP) to address the cost of care for all health plans overseen by the assigned position which includes metrics for utilization and quality management. Develops mitigating strategies to ensure goals are met or exceeded. Works closely with the clinical care management to ensure effective staff case review.
• Responsible for implementing Magellan and national and local medical policies/procedures.  Provides input regarding the need for modifications and additions to medical policy. May participate on corporate medical policy and clinical gu