JOB SUMMARY

The Behavioral Health Medical Director position is responsible for providing clinical guidance and consultation to the Behavioral Health Service Coordination and Utilization Management/Appeals Teams. They will facilitate integrated BH Rounds and interact directly with Psychiatrists, Behavioral Health Providers, and other clinical professionals who consult on various processes and programs. The Behavioral Medical Director is part of a leadership team that manages development and implementation of evidence-based guidelines and medical expense initiatives and will advise leadership on health care system improvement opportunities. They are responsible for maintaining the clinical integrity of the program, including timely coverage determinations, medical necessity reviews and determinations, appeals, peer-to-peer discussions, and consultations with providers and other community-based clinicians, including general practitioners. They will work collaboratively with the Health Plan Medical Director, and the Health Plans Clinical, Network and Quality teams.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Responsible for making clinical coverage determinations in accordance with the terms of members benefit plans, clinical policies, and objective and evidence - based on written clinical guideline. Adhere to all applicable turnaround time requirements in making coverage and medical necessity determinations, appeal / dispute review decisions, and complaint review decisions, and in notifying members and/or the practitioners in writing, and verbally when required.
• Provide clinical guidance and consultation to the clinical staff at all levels of care in the benefit plan. Keep current regarding Evidence Based Practices and treatment philosophies including those that address Recovery and Resilience. Knowledge of post-acute care planning such as home care, discharge planning, case management, and disease management.
• Focus on delivery of cost-effective quality care that incorporates recovery, resiliency and person-centered services for all lines of business. Responsible for Level of Care guidelines and utilization management protocols. Collaborates and coordinates with the BH Sr. Manager and BH Director regarding service coordination and care coordination activities.
• Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including, specific departmental process improvement plans.

QUALIFICATIONS:

• Education/Specialized Training/Licensure: MD/DO, holds a valid Texas license to practice medicine and be registered as a physician in the State of Texas. Board Certified or eligible Psychiatrist for initial employment. Board certification is required. Must meet credentialing criteria.
• Work Experience (Years and Area): Three (3) years experience as a practicing psychiatrist post residency; Adult Psychiatrist preferred; Child and Adolescent Psychiatry accepted. Experience working with community-based programs and resources designed to aid the State Medicaid and Medicare population required. Knowledge of post- acute care planning such as home care, discharge planning, and disease management.
• Management Experience (Years and Area): 2 years of management experience
• Software Proficiencies: Microsoft Office (Word, Excel, Outlook, PowerPoint)
• Other: Advanced education and training; Adult Psychiatrist preferred; Child and Adolescent Psychiatry Accepted