Clinical - Medical Director

Position: Clinical - Medical Director - 210034
Location: Voltido

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 requirements
Behavioral 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…