BH Medical Director (Per Diem)

WellSense Health Plan

147d•Remote

About The Position

The per diem Medical Director - Behavioral Health supports the Office of Clinical Affairs and Behavioral Health teams with medical management activities, including daily medical necessity reviews, medical policy evaluation, utilization trend management, quality, appeals and grievances, and pharmacy reviews. The position provides clinical case review, consultation, and oversight of utilization management activities in compliance with federal, state, and NCQA requirements. The role is per diem, with availability required 1–2 days per week for the full business day. Work is normally performed in a typical remote interior/office environment, and travel to locations within New Hampshire and Massachusetts may be required. The position collaborates with clinical and operational partners to improve population health, care quality and experience, and overall cost of care. It also contributes to clinical initiatives, committees, quality and pharmacy activities, and strategic planning as requested. Indirect technical direction is provided to the organization, and general direction is received weekly.

Requirements

Graduate of an accredited allopathic or osteopathic medical school with an MD or DO degree.
8–10+ years of related experience, including at least 5 years of direct clinical experience.
Current unrestricted MD licensure in Massachusetts and New Hampshire, or ability to obtain it within a reasonable timeframe.
No restriction on participation in Medicare or Medicaid programs.
Excellent demonstrated clinical skills and knowledge.
Excellent written and verbal communication skills.
Comprehensive knowledge of accrediting organizations such as NCQA.
Comprehensive knowledge of InterQual protocols, HEDIS, and other quality measures.
Knowledge of Medicare and state Medicaid regulations, guidelines, and standards.
Proven leadership and relationship-building skills.
Knowledge of managed care principles and processes.
Ability to work independently with intermittent supervision.
Ability to meet appropriate turnaround times and deadlines while maintaining high-quality, reliable results.
Ability to travel to locations within New Hampshire and Massachusetts.
Regular and reliable attendance.

Nice To Haves

Three years of medical management experience in a managed care setting is ideal.
Active or lifetime board certification in psychiatry (Child and Adolescent specialty) from the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry.
Pre-employment background check.

Responsibilities

Provide clinical case review, consultation, and oversight for utilization management activities in compliance with federal, state, and NCQA requirements.
Review prior authorizations, concurrent reviews, and retrospective medical necessity reviews that do not meet standard criteria, and determine coverage.
Work with the Senior Medical Director of Behavioral Health to identify appropriate use of InterQual criteria and Medical Policy.
Help ensure consistent medical decision-making among physician reviewers, including contracted physicians.
Conduct clinical reviews of appeals and grievances in compliance with federal, state, and NCQA requirements.
Develop and support clinical initiatives that advance department quality improvement and utilization management goals.
Review claims involving complex, controversial, unusual, or new services to determine medical necessity and appropriate payment.
Collaborate with hospital physicians, medical directors, primary care physicians, and nurse case managers on activities and initiatives to improve population health, care quality and experience, and cost of care.
Participate in and chair clinical committees as assigned by the Senior Medical Director of Behavioral Health.
Support quality and pharmacy committees and activities.
Provide input to the Office of Clinical Affairs strategic planning process as requested.
Represent the Chief Medical Officer or Senior Medical Directors in Massachusetts, New Hampshire, and other locations as requested.