Medical Director – Behavioral Health

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

📋 Description

• Provides insights from a physician's perspective and collaborates in the development and enhancement of Capital’s Behavioral Health (BH) program and strategy.

• Engages in and offers advice to Capital committees (such as Quality Improvement Committees, Utilization Management Committees, and Member Safety Committee) regarding BH topics and strategy formulation.

• Oversees, guides, consults, and lends expertise to Capital’s BH clinical operations, covering areas such as utilization management, care management, complex case evaluations, and clinical rounds.

• May offer limited cross-coverage support for Care Management and Utilization Management tasks, including consultations on complex cases, clinical rounds, or care coordination initiatives as needed by the business.

• Analyzes data to identify trends related to BH clinical operations and provides insights on medical necessity criteria and/or medical policies that inform BH utilization management decisions and subsequent appeals.

• Collaborates across departments (internally) and with key external stakeholders, including Capital’s network providers, to achieve Triple Aim outcomes.

• Contributes BH expertise to shape clinical programs and services that enhance quality and improve HEDIS, STAR, and CAHPS metrics.

• Works directly with Capital network providers and within Capital to advocate for provider practice transformation in alignment with Capital’s value-based delivery models.

• Establishes connections and regular communications with key BH network providers to work together on initiatives aimed at improving health outcomes for Capital’s members.

• Provides clinical leadership in the creation and evolution of strategies to enhance access and availability of BH care and services to Capital members, including physical and BH integration models (collaborative care models) and integrated care management programs, among others.

• Leads clinically in the formulation and execution of the strategic direction for Capital’s BH strategy, encompassing any vendor-supported programs and services.

• Aims to promote Capital’s clinical vision and programs within the local medical community and throughout Capital’s 21-county service area.

• Reviews and interprets data to facilitate transformation in improving member health, care experience, and medical expenses.

• Supports organizational accreditation initiatives and regulatory review processes, including participation in key committees and quality improvement efforts.

• Conducts activities in compliance with all relevant regulatory entities, including NCQA, CMS, PID, and DOH, among others.

• Performs other related tasks and assignments as requested and directed.

⛳️ Requirements

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

• A minimum of eight years of experience in healthcare with a focus on analysis and process optimization.

• Experience in a Managed Care Organization and/or health insurance plan is preferred.

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

• Knowledge of and prior engagement with complex and unique challenges within the healthcare industry.

• Awareness of health plan regulatory requirements, including those set by CMS, NCQA, and the DOH.

• MD or DO Degree, along with appropriate Board Certification.

• A current, unrestricted license in Pennsylvania as an MD or DO.

• Must be currently covered by, or eligible for, medical liability insurance.

• A valid Pennsylvania driver’s license is required.

🏝️ Benefits

• Medical, Dental & Vision coverage

• Retirement Plan

• Generous time off including Paid Time Off

• Holidays

• Volunteer time off

• Incentive Plan

• Tuition Reimbursement