Behavioral Health Medical Director

This is a fully remote position, open to applicants in Texas.

📋 Description

• Assist the Chief Medical Director in directing and coordinating the medical management, quality improvement, and credentialing functions for the business unit.

• Provide medical leadership across all utilization management, cost containment, and medical quality improvement initiatives.

• Conduct medical review activities related to utilization review, quality assurance, and the assessment of complex, controversial, or experimental medical services, ensuring timely and high-quality decision-making.

• Support the effective execution of performance improvement initiatives for capitated providers.

• Aid the Chief Medical Director in planning and establishing goals and policies aimed at enhancing the quality and cost-effectiveness of care and services for members.

• Offer medical expertise in the operation of approved quality improvement and utilization management programs in compliance with regulatory, state, corporate, and accreditation standards.

• Assist the Chief Medical Director in the operations of physician committees, including their structure, processes, and membership.

• Conduct regular rounds to assess and coordinate care for high-risk patients, working collaboratively with care management teams to optimize outcomes.

• Effectively collaborate with clinical teams, network providers, the appeals team, and medical and pharmacy consultants to review complex cases and medical necessity appeals.

• Participate in provider network development and new market expansion as appropriate.

• Contribute to the development and implementation of physician education on clinical issues and policies.

• Identify utilization review studies and assess adverse trends in the usage of medical services, unusual provider practice patterns, and the adequacy of benefit/payment components.

• Identify clinical quality improvement studies to help reduce unwarranted variations in clinical practice, thereby enhancing the quality and cost of care.

• Interface with physicians and other providers to facilitate the implementation of recommendations aimed at improving utilization and healthcare quality.

• Review claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment.

• Develop partnerships with the provider community through the establishment and implementation of medical management programs.

• As necessary, represent the business unit before various stakeholders both locally and nationally on medical philosophy, policies, and related issues.

• Represent the business unit at relevant state committees and other ad hoc committees.

• May be required to work weekends and holidays in support of business operations, as needed.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy.

• Preferred experience in Utilization Management and knowledge of quality accreditation standards.

• Actively practicing medicine.

• Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.

• Preferred experience in treating or managing care for a culturally diverse population.

• 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 specialty is required).

• Current Texas state license as an MD or DO without restrictions, limitations, or sanctions from government programs.

• For Behavioral Health only - Board certification by the American Board of Psychiatry and Neurology.

• Current state medical license without restrictions.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work approach with remote, hybrid, field, or office work schedules.