Behavioral Health Medical Director - Clinical Appeals

Job Summary The Behavioral Health Medical Director is responsible for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing. Essential Functions Assume responsibility for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing Serve as the clinical lead in developing and implementing evidenced based clinical policies and practices Participate in regulatory/accreditation reviews Assume key role in quality improvement initiatives, case management activities and member safety activities (i.e. incident management) BH coverage determination for utilization management to ensure members receive appropriate and medically necessary care in the most cost-effective setting Oversight and quality improvement activities associated with case management activities Provide guidance to BH orientation and network development/ recruitment in conjunction with provider relations, value-based contracting, support of episodes of care and full integration of BH services Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate Represent CareSource as the primary clinical liaison to members, providers and State agencies Support of regulatory and accreditation functions (e.g. CMS, State, NCQA and URAC) and compliance for all programs Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives Collaborate with market/product leaders to help define market strategy Community collaborative participation Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns Provide cross-coverage for other Medical Directors and/or markets, as needed Support staff by providing training, clinical consultation, and clinical case review for members including Medical Advisement meetings Perform any other job duties as requested Education & Experience Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is required Successful completion of a residency training program in psychiatry is required Minimum of three (3) years of clinical practice experience is required Experience in safe prescribing is required Managed care medical review/medical director experience is preferred Competencies, Knowledge, and Skills Basic Microsoft Word skills Excellent communication skills, both written and oral Ability to work well independently and within a team environment Ability to create strong relationships with Providers and Members Previous Institute for Healthcare Improvement (IHI) or equivalent training participation is preferred High ethical standards Attention to detail Critical listening and systematic thinking skills Ability to maintain confidentiality and act in the company’s best interest Ability to act with diplomacy and sensitivity to cultural diversity Decision making/problem solving skills Conflict resolution skills Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns Leadership experience and skills Licensure & Certification Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is required Board Certification in Psychiatry is required Re-certification, as required by specialty board, must be maintained MCG Certification is required or must be obtained within six (6) months of hire Working Conditions General office environment; may be required to sit or stand for extended periods of time May be required to work evenings/weekends May be required to travel in-state to fulfill duties of position Compensation Compensation Range: $195,200.00 - $341,600.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. Equal Opportunity Statement CareSource is an Equal Opportunity Employer. #J-18808-Ljbffr