Position Description:
Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”
The Behaviroal Health Medical Director provides medical guidance and support to the full spectrum of to Capital’s behavioral health (BH) program. Supports appropriate Utilization Management goals and objectives.
Provides professional leadership and direction to the functions within the Utilization Management Department.
*This is an independently contracted role, approximately 15-20 hours/week, Two Holidays/Year
*To be considered, you must have a current license to practice in the state of PA
Responsibilities and Qualifications:
- Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
- Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements
- Engage with requesting providers as needed in peer-to-peer discussions
- Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
- Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
- Makes coverage determinations in instances where requested services do not meet medical necessity criteria or where benefit exclusions require medical evaluation.
- Makes medical necessity determinations on appeals and grievances, assuring that different reviewers conduct each level of review.
- Provides Medical Director leadership to Vendor relationships as directed by the Managing Medical Director.
- Supports organizational accreditation efforts and regulatory review processes: Prior- Authorization, Concurrent Review, Medical Claims Review, Case Management, Disease Management, Pharmacy Management, and Health Education programs.
- Performs other related duties and assignments as directed.
Knowledge:
- Knowledge of current and emerging BH trends, including physical and behavioral health integration models,
- population health, and alternative payment models
- Knowledge of and prior involvement with complex and unique issues within the health care industry
- Knowledge of health plan regulatory requirements, including CMS, NCQA, and the DOH
- Knowledge of current and emerging medical treatment modalities.
- Familiarity with National Committee for Quality/URAC standards.
Skills:
- PC literacy and ability to perform electronic research and respond to electronic requests
- Team oriented attitude with the ability to work and interact with all levels both within and outside of CBC
- Ability to effectively multi-task under pressure, meet deadlines, and deliver high-quality work
- Ability to move from broad strategic perspective to tactical implementation and translate thoughts into actionable plans to drive performance
- Ability to convey complex or technical information in a manner that others can understand.
- Demonstrated organizational and time management skills.
- Self-motivated and works independently; highly accountable.
- Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions, and devise appropriate courses of action
- Demonstrated ability to drive results to completion while managing multiple projects and priorities competing for resources.
- Ability to complement leadership and other team members in their responsibilities and roles
Experience:
- A minimum of five years of clinical experience, post residency, including both inpatient and outpatient mental health and/or substance use disorder.
- At least three years’ experience in managed care, utilization review, and/or quality management.
- Managed Care Organization and/or health insurance plan experience preferred.
Education, Certification, and Licenses:
- Minimum requirements include an MD or DO Degree, as well as appropriate Board Certification in Psychiatry.
- Current unrestricted licensure in Pennsylvania as an MD or DO.
- Currently covered by, or eligible to be covered by, medical liability insurance.
Physical Demands:
- While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.