Guide Healthcare

Medical Director

• Performing physician-level utilization management reviews for behavioral health services across all applicable levels of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient services
• Rendering medical necessity determinations using Company-approved, evidence-based criteria (e.g., InterQual®, MCG®, or plan-specific guidelines)
• Reviewing escalated, complex, and reconsideration cases, including first- and second-level appeals, as requested
• Ensuring determinations are timely, clinically appropriate, and consistently applied across commercial product lines
• Conducting peer-to-peer consultations with treating psychiatrists and other behavioral health providers
• Communicating clear, clinically sound rationales for utilization management decisions
• Supporting resolution of provider disputes related to medical necessity or level-of-care determinations
• Applying utilization management criteria and processes in compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA)
• Ensuring non-quantitative treatment limitations (NQTLs), including prior authorization requirements, review standards, and clinical criteria application, are comparable to and no more stringent than those applied to medical/surgical benefits
• Supporting parity analyses, documentation, and regulatory inquiries as requested
• Providing clinical input on parity-related policies, utilization management practices, and corrective action plans
• Performing utilization management activities in alignment with NCQA Health Plan Accreditation standards
• Supporting readiness for NCQA surveys, audits, and corrective actions related to behavioral health utilization management
• Assisting with the development, review, or refinement of utilization management policies and procedures to maintain accreditation compliance
• Serving as a consultative clinical resource to behavioral health utilization management nurses, care managers, and operational leaders
• Providing recommendations to improve utilization management consistency, quality, efficiency, and provider experience
• Participating in scheduled or ad hoc clinical, quality, or utilization review meetings as requested

Contract Behavioral Health Utilization Management Medical Director – Psychiatry

Manager

• Conducting in-depth telephonic assessments to understand each patient’s medical, psychosocial, and social needs.
• Reviewing and updating medical histories—including medications, chronic conditions, and preventive care.
• Developing individualized care plans and guiding patients through their treatment goals and care options.
• Providing empathetic, evidence-based education on chronic disease management and preventive health.
• Monitoring progress by phone, adjusting care plans, and ensuring patients stay connected to their providers.
• Completing Medicare Annual Wellness Visits (AWVs) via telehealth under physician supervision.
• Partnering with Healthguides who support non-clinical needs like scheduling, transportation, food assistance, and SDOH resources.
• Performing proactive outreach and timely follow-ups to maintain continuity of care and patient engagement.
• Advocating for patients, helping them access the right resources at the right time.
• Documenting clearly and accurately in the EHR and care-management systems during and after calls.
• Supporting quality outcomes (HEDIS, NCQA) by coordinating preventive services and managing chronic conditions.
• Participating in virtual meetings, ongoing education, and clinical training to stay current with care standards.
• Using multiple communication methods (phone, text, patient portals, email, AI-supported tools) to reach high-risk patients.
• Collaborating in AI-driven outreach programs that help connect with vulnerable populations.
• Protecting patient privacy in a secure, private home workspace.
• Performing additional responsibilities as needed to support patients and the care team.

RN Case Manager, Complex Pediatric Specialty

Customer Support

• Assess training needs using data and performance trends.
• Design, develop, and facilitate New Hire Training for Customer Guides, Guide Coaches, and CX Managers.
• Build cross-training, upskill, and refresher programs aligned with operational priorities.
• Maintain a structured training roadmap based on product changes, seasonality, and skill gaps.
• Create engaging content—presentations, simulations, job aids, videos, and workflow guides.
• Measure training effectiveness through assessments, QA outcomes, and performance metrics.
• Partner with CX Managers and Guide Coaches to identify emerging training needs.
• Own the CX Quality Assurance framework to ensure interaction quality meets evolving customer expectations.
• Partner with Guide Coaches to calibrate QA scoring and unify coaching insights.
• Refine QA rubrics and conduct deep dives to identify behavioral, procedural, and systemic improvements.
• Use QA trends to inform training updates and policy enhancements.
• Create and maintain CX Standards, SOPs, workflows, scripts, and knowledge documents.
• Translate complex processes into clear, simple instructions for frontline teams.
• Ensure documentation is accurate, up-to-date, and version-controlled.
• Monitor CSAT survey performance and identify drivers of satisfaction and dissatisfaction.
• Translate feedback into actionable improvements for scripts, SOPs, training, and workflows.
• Produce regular CSAT and QA insight reports for CX leadership.
• Serve as the CX training and QA subject matter expert for product, workflow, and technology initiatives.
• Ensure frontline readiness for new launches through training and documentation updates.
• Champion a coaching-first culture centered on empathy, capability building, and continuous improvement.

Contract Behavioral Health Utilization Management Medical Director – Psychiatry

RN Case Manager, Complex Pediatric Specialty

Customer Experience Manager