Behavioral Health Medical Director -Clinical Appeals(Preferred Experience in Uti

Job Summary:The Behavioral Health Medical Director is responsible for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing.Essential Functions:Assume responsibility for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribingServe as the clinical lead in developing and implementing evidenced based clinical policies and practicesParticipate in regulatory/accreditation reviewsAssume key role in quality improvement initiatives, case management activities and member safety activities (i.e. incident management)BH coverage determination for utilization management to ensure members receive appropriate and medically necessary care in the most cost-effective settingOversight and quality improvement activities associated with case management activitiesProvide guidance to BH orientation and network development/ recruitment in conjunction with provider relations, value-based contracting, support of episodes of care and full integration of BH servicesAssist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriateRepresent CareSource as the primary clinical liaison to members, providers and State agenciesSupport of regulatory and accreditation functions (e.g. CMS, State, NCQA and URAC) and compliance for all programs Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standardsParticipate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiativesCollaborate with market/product leaders to help define market strategyCommunity collaborative participationParticipate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concernsProvide cross-coverage for other Medical Directors and/or markets, as neededSupport staff by providing training, clinical consultation, and clinical case review for members including Medical Advisement meetingsPerform any other job duties as requestedEducation and Experience:Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is requiredSuccessful completion of a residency training program in psychiatry is requiredMinimum of three (3) years of clinical practice experience is requiredExperience in safe prescribing is requiredManaged care medical review/medical director experience is preferredCompetencies, Knowledge and Skills:Basic Microsoft Word skillsExcellent communication skills, both written and oralAbility to work well independently and within a team environmentAbility to create strong relationships with Providers and MembersPrevious Institute for Healthcare Improvement (IHI) or equivalent training participation is preferredHigh ethical standardsAttention to detailCritical listening and systematic thinking skillsAbility to maintain confidentiality and act in the company’s best interestAbility to act with diplomacy and sensitivity to cultural diversityDecision making/problem solving skillsConflict resolution skillsStrong sense of mission and commitment of time, effort and resources to the betterment of the communities servedAbility to analyze healthcare data from a variety of sources to evaluate physician practice patternsLeadership experience and skillsLicensure and Certification:Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is requiredBoard Certification in Psychiatry is requiredRe-certification, as required by specialty board, must be maintainedMCG Certification is required or must be obtained within six (6) months of hireWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeMay be required to work evenings/weekendsMay be required to travel in-state to fulfill duties of positionCompensation Range:$191,400.00 - $334,900.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.Compensation Type (hourly/salary):SalaryOrganization Level Competencies Create an Inclusive EnvironmentCultivate PartnershipsDevelop Self and OthersDrive ExecutionInfluence OthersPursue Personal ExcellenceUnderstand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.Originally posted on Himalayas

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