Behavioral Health Medical Director-Utilization Management- Independent Contractor

Capital Blue Cross•Harrisburg, PA

3d•Remote

About The Position

The Behavioral Health Medical Director provides medical guidance and support to the full spectrum of Capital's behavioral health (BH) program. Supports appropriate Utilization Management goals and objectives. Provides professional leadership and direction to the functions within the Utilization Management Department. This is an independently contracted role, approximately 15-20 hours/week, Two Holidays/Year.

Requirements

Current license to practice in the state of PA
A minimum of five years of clinical experience, post residency, including both inpatient and outpatient mental health and/or substance use disorder.
At least three years’ experience in managed care, utilization review, and/or quality management.
MD or DO Degree
Appropriate Board Certification in Psychiatry
Current unrestricted licensure in Pennsylvania as an MD or DO.
Currently covered by, or eligible to be covered by, medical liability insurance.

Nice To Haves

Managed Care Organization and/or health insurance plan experience preferred.
Knowledge of current and emerging BH trends, including physical and behavioral health integration models, population health, and alternative payment models
Knowledge of and prior involvement with complex and unique issues within the health care industry
Knowledge of health plan regulatory requirements, including CMS, NCQA, and the DOH
Knowledge of current and emerging medical treatment modalities.
Familiarity with National Committee for Quality/URAC standards.
PC literacy and ability to perform electronic research and respond to electronic requests
Team oriented attitude with the ability to work and interact with all levels both within and outside of CBC
Ability to effectively multi-task under pressure, meet deadlines, and deliver high-quality work
Ability to move from broad strategic perspective to tactical implementation and translate thoughts into actionable plans to drive performance
Ability to convey complex or technical information in a manner that others can understand.
Demonstrated organizational and time management skills.
Self-motivated and works independently; highly accountable.
Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions, and devise appropriate courses of action
Demonstrated ability to drive results to completion while managing multiple projects and priorities competing for resources.
Ability to complement leadership and other team members in their responsibilities and roles

Responsibilities

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements
Engage with requesting providers as needed in peer-to-peer discussions
Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
Makes coverage determinations in instances where requested services do not meet medical necessity criteria or where benefit exclusions require medical evaluation.
Makes medical necessity determinations on appeals and grievances, assuring that different reviewers conduct each level of review.
Provides Medical Director leadership to Vendor relationships as directed by the Managing Medical Director.
Supports organizational accreditation efforts and regulatory review processes: Prior- Authorization, Concurrent Review, Medical Claims Review, Case Management, Disease Management, Pharmacy Management, and Health Education programs.
Performs other related duties and assignments as directed.