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Behavioral Health Medical Director – Clinical Appeals
CareSourceBehavioral Health Medical Director overseeing patient safety with focus on safe prescribing, leading clinical initiatives and quality compliance for CareSource.
About the role
Key responsibilities & impact- Assume responsibility for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing
- Serve as the clinical lead in developing and implementing evidenced based clinical policies and practices
- Participate in regulatory/accreditation reviews
- Assume 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 setting
- Oversight and quality improvement activities associated with case management activities
- Provide 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 services
- Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate
- Represent CareSource as the primary clinical liaison to members, providers and State agencies
- Support 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 standards
- Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
- Collaborate with market/product leaders to help define market strategy
- Community collaborative participation
- Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
- Provide cross-coverage for other Medical Directors and/or markets, as needed
- Support staff by providing training, clinical consultation, and clinical case review for members including Medical Advisement meetings
- Perform any other job duties as requested
Requirements
What you’ll need- Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is required
- Successful completion of a residency training program in psychiatry is required
- Minimum of three (3) years of clinical practice experience is required
- Experience in safe prescribing is required
- Managed care medical review/medical director experience is preferred
Benefits
Comp & perks- comprehensive total rewards package
- bonus tied to company and individual performance
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
safe prescribingclinical policiesquality improvementcase managementutilization managementclinical care standardsclinical consultationfraud investigationmedical review
Soft Skills
leadershipcommunicationcollaborationtrainingguidance
Certifications
Medical Degree (MD)Doctor of Osteopathic Medicine (DO)