Remote Behavioral Medical Director, Eastern Region

Position Purpose: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

- 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, ensuring timely and quality decision making.

- 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.

- Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.

- Collaborates effectively with clinical teams, network providers, appeals team, 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.

- As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.

- Represents the business unit at appropriate state committees and other ad hoc committees.

- May be required to work weekends and holidays in support of business operations, as needed.

- Medical Doctor or Doctor of Osteopathy. - Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. - Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. - Experience treating or managing care for a culturally diverse population preferred.

- Board certification by the American Board of Psychiatry and Neurology. - Certification in Child Psychiatry, preferred. - Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.