Medical Director - Behavioral Health (Medicaid)

Highmark Health • PA, Working at Home - Pennsylvania, PA

11d • $227,600 - $385,000 • Onsite

About The Position

This job plays a crucial role in the corporation’s success, and under direction by the chief medical officer and in collaboration with the senior director for behavioral health, works closely with all divisions and departments within the corporate structure to provide clinical consultation and support with regard to the behavioral health and addiction services program strategy and development, compliance with accepted medical standards, and practitioner/provider education. The incumbent is an integral part of the behavioral health utilization management team and assists utilization management staff by direct supervision or as otherwise appropriate to ensure delivery of quality and cost–effective care, member/provider satisfaction, and quality outcomes.

Requirements

• Doctorate Degree
• 5 years as a Behavioral Health Physician OR Addiction Medicine Physician
• 3 years in a medical staff leadership or healthcare management role in Managed Care
• 3 years with Formal Quality and/or Utilization Management programs
• Unrestricted PA and WV Medical License with ability to obtain DE Medical License and other state licenses as needed to support business growth
• Board Certification in Behavioral Health
• Proven ability to manage a project in order to accomplish established goals within a reasonable time period and through the use of developed organization and leadership skills
• Excellent communication and public speaking skills, well-developed interpersonal skills, and ability to interact effectively with members, practitioners/providers, colleagues, and local State and Federal agencies
• Familiarity with applicable State and Federal regulations and NCQA requirements for accreditation

Nice To Haves

• Master's Degree in Business Administration/Management or Public Health
• 7 years as a Behavioral Health Physician OR Addiction Medicine Physician
• Professional UR/QI certification

Responsibilities

• Provide utilization management reviews and clinical support for Medicaid, Medicare (DSNP) membership and Behavioral Health Pharmacy requests; communication of the decisions to the member and provider.
• Provide decisions for member and provider appeals and grievances, including ALJ and SFH
• Provide backup coverage for other BH medical directors in the Government segment as needed for PTO
• Provide clinical input into healthcare management services’ activities relating to behavioral health and addiction medicine, including for example, care and case management, clinical program development, and network management.
• Provide clinical input to the Quality team to address HEDIS and NCQA metrics.
• Working with the network management and provider relations teams, act as a liaison for Highmark Wholecare and Highmark Health Options WV with practitioners/providers through ongoing communications and monitoring of services utilized.
• Contribute to development of the strategic direction for behavioral health for HWC and HHO WV as a member of the delivery system transformation team, help direct deployment and management of the virtually integrated partnership model.
• Serve as a resource for information and consultation on the issues related to utilization management, clinical services and medical affairs, including such issues as case management, disease state management programs, health risk assessments or other topics of general interest.
• Analyze utilization data and various forms of health care data available within and external to the corporation to evaluate effectiveness of clinical initiatives and care and case management processes.
• Identify factors for below quality standards and intervene as the spokesperson with local practitioners/providers to resolve care and case management issues and participate in the development of long-term strategies to create cost-effective medical care.
• Investigate and implement opportunities for cost savings initiatives to meet segment financial goals.
• Monitor clinical resource allocation, utilization and referral patterns, patient satisfaction, and clinical outcomes across the practitioner and provider network and at times make denials of services based on the absence of medical necessity.
• Provide findings to senior leadership and lead development of corrective action plans as indicated.
• Work with the credential staff to review provider applicants and to make decisions regarding approval, denial, and/or terminations according to Highmark Wholecare’s and HHO WV policies and NCQA standards.
• Develop a working knowledge of the credentialing process and criteria and participate in its design.
• Regionally supervise and/or collaborate the activities/directives of the QI operations staff and committees.
• Attend corporate QI committee meetings, and report on regional actions related to committee function.
• Serve as a liaison to the state regulators (PA DHS, PA OLTL, & WV BMS)
• Other duties as assigned or requested.

Benefits

• Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree