Behavioral Health Medical Director – Clinical Appeals

Job not on LinkedIn

🕒 May 14

🇺🇸 United States – Remote

💵 $195.2k - $341.6k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

⚕️ Healthcare Insurance

Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• 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

• 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

• comprehensive total rewards package • bonus tied to company and individual performance