MD Behavioral Health Psychiatry

Horizon Healthcare Services•Newark, NJ

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 information from multiple 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 authorization and review decisions, case management, medical necessity, and medical appropriateness. It also participates in complex case planning and management, communicates management plans to providers, guides staff in interpreting medical policy, assists with policy and technology assessments, and supports appeal reviews. The position may also contribute to provider credentialing, profiling, communications, and network development initiatives.

Requirements

Board certification as an MD or DO and a current unrestricted license to practice medicine in a primary care specialty.
At least five years of clinical experience.
At least three years of medical management experience in a managed care setting.
Knowledge of utilization management principles and procedures, URAC Health UM Standards, and peer review.
Excellent understanding of managed care principles and concepts.
Knowledge of the health insurance payor business, including 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.
For the Child Psychiatrist addendum: completion of an approved Psychiatry residency and an accredited Child and Adolescent Psychiatry fellowship; Child Psychology board eligible by the start date.
For Government Programs: active, unrestricted New Jersey MD or DO license required. The posting also states that an active, unrestricted New Jersey MD or DO license is required for HCM.

Responsibilities

Provide medical expertise for the Behavioral Health function, based on knowledge of health care delivery systems, utilization and reimbursement methods, and treatment protocols.
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 the interpretation of medical policy.
Assist with medical policy and technology assessments and recommendations.
Assist with or consult on the appeal review process.
May provide input on provider credentialing, profiling, and communication initiatives and network development.
Analyze data from a variety of sources to identify trends or issues.
Participate in internal or external committees as assigned.