MD Behavioral Health Psychiatry
About The Position
This position provides day-to-day guidance, support, and medical leadership for utilization management activities and decisions within the Behavioral Health function. It supports the Medical Director-Behavioral Health in all aspects of utilization management, analyzes data from various sources to identify trends or issues, and participates in internal or external committees as assigned. The role provides medical expertise and consultation to behavioral health clinician reviewers on utilization review, case management, medical necessity, and medical appropriateness. It also contributes to complex case planning and management, medical policy interpretation and assessment, appeals, provider initiatives, and network development.
Requirements
- Board certification as an MD or DO and a current unrestricted license to practice medicine in one of the primary care specialties.
- At least five years of clinical experience.
- Three or more years of medical management experience in a managed care setting.
- For the Child Psychiatrist addendum: completion of an approved Psychiatry residency and an accredited Child and Adolescent Psychiatry fellowship.
- For the Child Psychiatrist addendum: Child Psychology Board eligible by the start date.
- For Government Programs: active unrestricted New Jersey MD or DO license required; HCM.
- Active unrestricted New Jersey MD or DO license required.
- Knowledge of utilization management principles and procedures, URAC Health UM Standards, and peer review.
- Excellent understanding of managed care principles and concepts.
- Knowledge of health insurance payer business and operations.
- Broad clinical knowledge and understanding of current health care issues.
- Broad clinical skills to understand medical issues and discuss them with physicians.
- Ability to exercise independent judgment in making medical necessity decisions.
- Ability to interpret and apply medical policy and provide guidance to others.
- Strong communication skills.
- Analytical skills to evaluate data from various sources and identify trends and issues.
Responsibilities
- Provide medical expertise based on knowledge of health care delivery systems, utilization and reimbursement methods, and treatment protocols for the Behavioral Health function.
- Support, guide, and consult with behavioral health clinician reviewers on pre-authorization, concurrent, and retrospective review issues or decisions.
- Support, guide, and consult with behavioral health clinician reviewers on case management issues or decisions.
- Support, guide, and consult with behavioral health clinician reviewers on medical necessity and medical appropriateness issues or decisions.
- Participate in the development, planning, and management of complex cases and communicate management plans to providers.
- Guide staff in interpreting medical policy and assist with medical policy and technology assessments and recommendations.
- Assist with or consult on the appeal review process.
- Provide input to provider credentialing, profiling, communication initiatives, and network development, as appropriate.
- Analyze data from a variety of sources to identify trends or issues.
- Participate in internal or external committees as assigned.
Benefits
- Comprehensive health benefits, including medical, dental, and vision.
- Retirement plans.
- Generous paid time off.
- Incentive plans.
- Wellness programs.
- Paid volunteer time off.
- Tuition reimbursement.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Ph.D. or professional degree
