Behavioral Health Medical Director

BlueCross BlueShield of South Carolina•Columbia, SC

3d•$206,011 - $413,523•Hybrid

About The Position

The Behavioral Health Medical Director provides medical leadership to specific health plan or LOB to include overseeing physician review, utilization review/quality assurance, directing case management, developing and implementing medical policies and standards, evaluating new technologies and treatments. In this role, you will identify trends in medical management and proactively aid in setting direction to improve these. The Behavior Health Medical Director that we seek will have extensive experience in the following areas: STRATEGIC AND CLINICAL LEADERSHIP The Medical Director provides clinical oversight for all behavioral health activities across utilization management, care coordination, quality, and population health for South Carolina Medicaid. The role ensures Healthy Blue’s BH strategy aligns with SCDHHS priorities, providing clinical authority to direct program strategy, oversee clinical policies, and support statewide goals such as improved transitions of care and reduced emergency department dependence. UTILIZATION AND COST MANAGEMENT The BH Physician Reviewer ensures defensible, evidence based utilization decisions; provides clinical review for complex and high cost cases; and partners with internal program integrity teams to identify inappropriate utilization patterns. This role directly impacts Healthy Blue’s cost of care performance while maintaining member safety and compliance with SCDHHS expectations for medically necessary, least restrictive care. MEMBER SAFETY, INTEGRATED CARE, AND HEALTH EQUITY This position provides clinical leadership for integrated BH/medical models, supports suicide prevention and crisis response initiatives, and oversees transitions-of-care strategies to reduce readmissions and adverse events. The role advances health equity by promoting culturally responsive care and addressing disparities across South Carolina’s rural and urban regions.

Requirements

Doctorate Degree - Medical Doctor (MD) with current active medical license, without restriction. If Behavioral Health, Medical Director – Doctor of Psychiatry with current active medical license, without restriction.
8 years post graduate experience in direct patient care.
Managed care knowledge and experience required.
Working knowledge of regulatory and accreditation entities, i.e., URAC, NCQA, DOI, and DOL standards.
Excellent verbal and written communication skills.
Excellent customer service, organizational, and presentation skills.
Good judgment skills.
Proficiency in spelling, punctuation, and grammar.
Ability to persuade, negotiate, or influence others, represent our company well.
Ability to work as a team member as well as a leader.
Active, unrestricted medical license from the United States and in the state of hire and current board certification in a recognized specialty.

Nice To Haves

Doctorate Degree - Medical Doctor (MD) with current active South Carolina medical license, without restriction.
Completion of a Psychiatry residency with preference for specialty in Child and Adolescent Psychiatry.
Strong knowledge of Medicaid programs, regulations and compliance.
Ability to develop and maintain positive relationships with peers, enterprise, customers, and partners.
Demonstrated ability to drive continuous improvement and cost reduction.
Ability to effectively collaborate with cross-functional teams.
Executive level presentation skills.
Experience working with the SC Department of Health and Human Services.

Responsibilities

Provides leadership and medical support on medical and regulatory matters.
Identifies trends in medical and pharmacy costs, utilization trends, and proactively makes recommendations and initiates solutions to impact these.
Provides leadership to clinical team and operations in order to increase compliance, improve efficiency, and increase communication.
Acts as resource for providers, staff, part time medical reviewers, and as requested, customers, on issues concerning medical policies and regulations.
Provides clinical support to Payment Integrity Unit(s) to analyze abuse patterns and recommend solutions.
Provides oversight and leadership with quality improvement and health plan and medical program accreditation(s).
Works with staff and other leadership in developing ideas related to quality initiatives, good clinical support, and outreach to the network.
Responsible for physician review (UM, Appeals, CM) - reviews physician and provider practice pattern analysis and other statistical data.
Conducts research into new or controversial medical procedures and technology.
Educates staff, network providers, and medical community on various aspects of medical policy and program administration.