Behavioral Health Medical Director – UM Optimization

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

📋 Description

• Support the Chief Medical Officer in overseeing and coordinating medical management, quality enhancement, and credentialing activities.

• Offer medical leadership for Utilization Management, cost control, and initiatives focused on medical quality improvement.

• Spearhead strategic planning and enhancement of Utilization Management processes.

• Assess completed tasks, interpret data, and make informed decisions regarding strategic process enhancements.

• Conduct medical evaluations for utilization review, quality assurance, and complex, controversial, or experimental services.

• Aid performance improvement efforts for capitated providers.

• Collaborate in setting objectives and policies to enhance the quality and cost-effectiveness of care.

• Provide medical insights for quality improvement and utilization management programs in line with regulatory, state, corporate, and accreditation standards.

• Assist in the structure, processes, and membership of physician committees.

• Perform regular visits for high-risk patients and coordinate with care management teams.

• Work alongside clinical teams, network providers, appeals teams, and medical and pharmacy consultants on complex cases and medical necessity appeals.

• Engage in provider network development and expansion into new markets.

• Support physician education on clinical matters and policies.

• Identify studies related to utilization review and clinical quality enhancement.

• Analyze adverse utilization trends, atypical provider practice patterns, and benefits/payment sufficiency.

• Collaborate with physicians and providers to execute recommendations aimed at improving utilization and healthcare quality.

• Review intricate claims to ascertain medical necessity and appropriate payment.

• Foster provider-community alliances through medical management initiatives.

• Represent the business unit in front of local and national audiences and at state or ad hoc committees as necessary.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy degree.

• Board certification in a medical specialty acknowledged by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.

• Certification in Psychiatry specialty is mandatory.

• Board certification from the American Board of Psychiatry and Neurology.

• Valid state medical license as an MD or DO without any restrictions, limitations, or sanctions from government programs.

• Experience in Utilization Management and familiarity with quality accreditation standards is preferred.

• Actively practicing medicine is preferred, but not essential.

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

• Experience in treating or managing care for a culturally diverse population is preferred.

• Payer/Managed Care experience is highly preferred.

• Availability to work weekends and holidays as required.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement support.

• Paid time off including holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.

• Additional incentives may be included in the overall compensation package.

• Equal opportunity employer dedicated to promoting diversity.