Behavioral Health Medical Director – Utilization Management

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

📋 Description

• Offer medical guidance and support across the entire range of Capital Blue Cross’s behavioral health program.

• Assist in achieving the objectives and goals of Utilization Management.

• Provide professional leadership and direction for functions within the Utilization Management Department.

• Conduct coverage reviews in alignment with member plan benefits and established coverage review policies.

• Make coverage determinations.

• Document findings from clinical reviews, actions taken, and outcomes in compliance with policies and regulatory/accreditation standards.

• Engage in peer-to-peer discussions with requesting providers as necessary.

• Interpret benefit language and policies during clinical coverage reviews.

• Communicate and collaborate with both network and non-network providers to ensure precise and timely benefit determinations.

• Educate providers regarding benefit plans and medical policies.

• Make coverage determinations when services do not fulfill medical necessity criteria or when benefit exclusions necessitate medical evaluation.

• Assess medical necessity on appeals and grievances, ensuring that different reviewers handle each level of review.

• Provide Medical Director leadership for vendor relationships as directed by the Managing Medical Director.

• Support organizational accreditation initiatives and regulatory review processes, which include prior authorization, concurrent review, medical claims review, case management, disease management, pharmacy management, and health education programs.

• Perform additional related duties as assigned.

⛳️ Requirements

• Possess a current unrestricted license to practice as an MD or DO in Pennsylvania.

• Hold an MD or DO degree.

• Have appropriate Board Certification in Psychiatry.

• Minimum of five years of clinical experience post-residency, encompassing both inpatient and outpatient mental health and/or substance use disorder.

• At least three years of experience in managed care, utilization review, and/or quality management.

• Currently covered by, or eligible for, medical liability insurance.

• Familiarity with current and emerging behavioral health trends, including physical and behavioral health integration models, population health, and alternative payment models.

• Understanding of complex and unique issues within the healthcare sector.

• Knowledge of health plan regulatory requirements, including CMS, NCQA, and DOH standards.

• Awareness of current and emerging medical treatment modalities.

• Familiarity with National Committee for Quality/URAC standards.

• Proficient in PC usage and capable of performing electronic research and responding to electronic inquiries.

• Ability to effectively manage multiple tasks under pressure, meet deadlines, and deliver high-quality work.

• Demonstrated skills in organization and time management.

• Proven problem-solving abilities with a knack for analyzing issues and developing suitable courses of action.

🏝️ Benefits

• Approximately 15–20 hours per week.

• Two holidays per year.

• Independent contractor arrangement.