Medical Director, Children's Behavioral Health

Excellus BCBS•Rochester, NY

5d•Remote

About The Position

This position assists the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. This role supports the HARP line of business. The Medical Director will provide medical leadership for utilization management, cost containment, and medical quality improvement activities. They will perform medical review activities for utilization review, quality assurance, and complex medical services. This role supports the implementation of performance improvement initiatives for capitated providers and assists the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. The Medical Director will provide medical expertise in the operation of quality improvement and utilization management programs, assist in the functioning of physician committees, and oversee physician advisors. They will utilize consultants for reviewing complex cases and appeals, participate in provider network development, and assist in developing physician education. The role involves identifying utilization review studies, evaluating adverse trends, and identifying clinical quality improvement studies. The Medical Director will interface with providers to implement recommendations, review claims for medical necessity and payment, and develop alliances with the provider community. They may represent the business unit on medical philosophy and policies and represent the business unit at state committees. The position requires adherence to high standards of integrity, member privacy, and participation in staff meetings. Level II responsibilities include reviewing medical literature, applying evidence-based principles, assessing internal trend reports, interacting with regulatory agencies, and providing clinical support to Sales and Marketing. Level II also provides clinical leadership for new utilization/case/quality management initiatives.

Requirements

Current New York State licensed physician.
Minimum 5 years of experience in a BH managed care settings or BH clinical setting (at least 2 of which are in a clinical setting).
Board certification in general psychiatry or certification in addiction medicine or certification in the subspecialty of addiction psychiatry.
Appropriate training and expertise in general psychiatry and/or addiction disorders.
Ability to identify, analyze and resolve complex medical issues.
Skills in evidence-based medicine.
Strong interpersonal skills essential for communication to staff at all levels of the organization.
Basic skill sets in electronic communication systems such as e-mail and Word.
Superior evidence-based medicine skill set
Strong interpersonal skills essential for communication to physicians in the community.
Strong verbal presentation skills to lead internal and external discussions at board levels
Advanced skill sets in electronic communication systems such as e-mail, Word, PowerPoint, and Excel.

Responsibilities

Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
Supports effective implementation of performance improvement initiatives for capitated providers.
Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
Oversees the activities of physician advisors.
Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participates in provider network development and new market expansion as appropriate.
Assists in the development and implementation of physician education with respect to clinical issues and policies.
Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
Develops alliances with the provider community through the development and implementation of the medical management programs.
May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues, as needed.
Represents the business unit at appropriate state committees and other ad hoc committees
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Reviews medical literature and applies evidence-based principles using high proficiency skills for a broad range of clinical services.
Reviews internal trend reports to assess present and future needs and opportunities.
Interacts with regulatory and accreditation agencies as assigned.
Provides clinical support to the Sales and Marketing divisions
Provides clinical leadership for the implementation of new utilization/case/quality management initiatives