Behavioral Health Medical Director – Clinical Appeals

📋 Description

• Take on the responsibility for ensuring the overall safety of patients with a behavioral health diagnosis, particularly focusing on safe prescribing practices.

• Act as the clinical lead in the development and implementation of evidence-based clinical policies and practices.

• Engage in regulatory and accreditation reviews.

• Play a pivotal role in quality improvement initiatives, case management activities, and member safety efforts (including incident management).

• Make decisions regarding behavioral health coverage for utilization management to guarantee that members receive appropriate and medically necessary care in the most cost-effective environment.

• Oversee and enhance quality improvement activities linked to case management operations.

• Provide support for behavioral health orientation and network development/recruitment in collaboration with provider relations, value-based contracting, support for episodes of care, and the full integration of behavioral health services.

• Assist in analyzing utilization data to pinpoint variances in patterns, offering feedback and education to MCP staff and providers as needed.

• Serve as the primary clinical liaison for CareSource, representing the organization to members, providers, and state agencies.

• Aid in regulatory and accreditation functions (such as CMS, State, NCQA, and URAC) and ensure compliance across all programs.

• Contribute to the development, implementation, and revision of clinical care standards and practice guidelines, ensuring adherence to nationally accepted quality standards.

• Participate in the formulation, implementation, and modification of the Quality Improvement Plan and corporate-level quality initiatives.

• Collaborate with market and product leaders to help define market strategy.

• Engage in community collaborative participation.

• Take part in the evaluation and investigation of cases suspected of fraud, abuse, and quality of care concerns.

• Provide cross-coverage for other Medical Directors and/or markets as required.

• Support staff by offering training, clinical consultation, and clinical case review for members, including Medical Advisement meetings.

• Perform any additional job duties as requested.

⛳️ Requirements

• A completed accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic Medicine (DO) is mandatory.

• Successful completion of a residency training program in psychiatry is essential.

• At least three (3) years of clinical practice experience is required.

• Proficiency in safe prescribing is essential.

• Experience in managed care medical review or as a medical director is preferred.

🏝️ Benefits

• Comprehensive total rewards package.

• Bonus linked to individual and company performance.