Behavioral Health Medical Director - UM Optimization

Position Purpose:
Assist the Chief Medical Officer to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

This is a remote BH Medical Director role providing medical leadership for Utilization Management (UM) and cost containment. The focus of this role is on strategic planning and optimization of UM processes. The Medical Director will evaluate completed work, analyze data, and make decisions on strategic process improvements. This role will directly support the CMO while working closely nursing leaders. Ideal candidate will have in-depth knowledge in the UM space who is passionate about strategic planning and data analysis. Applicants must be board certified in Psychiatry, including board certification by the American Board of Psychiatry and Neurology, and hold a current state medical license as an MD or DO without restrictions, limitations, or sanctions from government programs. Payer/ Managed Care experience is heavily preferred .

• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
• Supports effective implementation of performance improvement initiatives for capitated providers.
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
• Participates in provider network development and new market expansion as appropriate.
• Assists in the development and implementation of physician education with respect to clinical issues and policies.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
• Develops alliances with the provider community through the development and implementation of the medical management programs.
• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
• Represents the business unit at appropriate state committees and other ad hoc committees.
• May be required to work weekends and holidays in support of business operations, as needed.

Education/Experience:
Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine is preferred, but]]><