Medical Director - Behavioral Health

CVS Health•Work At Home-Texas, TX

5d•$174,070 - $374,920•Remote

About The Position

Aetna, a CVS Health Company, is seeking a Medical Director (Behavioral Health) to provide psychiatric leadership and physician oversight for utilization management and behavioral health care management. The role focuses on medical necessity decisions, high-risk cases, quality and appropriateness of care, and the development and evaluation of utilization management and clinical programs. The position is remote-based (work from home); candidates residing in Texas are preferred. Weekend coverage is required every 6–7 weeks.

Requirements

Board-certified Psychiatrist.
Currently licensed in Texas or able to become licensed in Texas.
Active and current state medical license without encumbrances.
Ability to obtain additional state licenses and provide utilization management coverage across multiple state health plans.
MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine).

Nice To Haves

Residence in Texas is preferred.
At least 5 years of clinical practice experience in health care delivery as a psychiatrist.
Experience with managed care, utilization review as a provider or manager of care, or physician advisor experience.
Child/Adolescent Board Certification.

Responsibilities

Provide leadership and day-to-day physician oversight for the utilization management team, including management of high-risk cases and medical necessity decisions.
Provide behavioral health care management to support appropriate, quality care and improve program and operational efficiency on clinical issues.
Participate in the appeals process, including investigating adverse events and quality-of-care concerns.
Provide psychiatric leadership to an interdisciplinary utilization management team through medical and clinical oversight, consultation, and training.
Oversee high-risk cases throughout treatment and levels of care, and make medical necessity decisions.
Assist with developing, implementing, monitoring, and evaluating the utilization management program and action plan to ensure quality and appropriateness of care.
Assist with developing, implementing, and interpreting medical policy, including medical necessity criteria, clinical practice guidelines, and new technology assessments.
Participate in developing, implementing, and evaluating clinical and medical programs.
Confer with behavioral health practitioners regarding patients with severe, complex, or treatment-resistant illnesses.
Identify and address quality-of-care concerns with providers involved in a member’s care.
Provide psychiatric leadership for NCQA-compliant clinical quality improvement activities in collaboration with clinical and quality improvement staff.
Participate in triage and referral for care management.
Provide weekend coverage every 6–7 weeks.
Perform other duties as deemed necessary.