Behavioral Health Medical Director – Utilization Management

🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $100 - $150 / hour

⏱ Part Time

🔴 Lead

👨‍⚕️ Medical Director

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Capital Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1938

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Capital Blue Cross is a health insurance company that offers a range of health plans for individuals, families, and employers. They serve customers in Central Pennsylvania and the Lehigh Valley, focusing on providing health coverage services such as Medicare plans, student health plans, and resources for managing medical care. Capital Blue Cross positions itself as a partner in health, emphasizing support for members' overall wellness and preventive health measures.

📋 Description

• Provide medical guidance and support to the full spectrum of Capital Blue Cross’s behavioral health program • Support appropriate Utilization Management goals and objectives • Provide professional leadership and direction to functions within the Utilization Management Department • Conduct coverage reviews based on member plan benefits and coverage review policies • Render coverage determinations • Document clinical review findings, actions, and outcomes in accordance with policies and regulatory/accreditation requirements • Engage with requesting providers in peer-to-peer discussions as needed • Interpret benefit language and policies during clinical coverage reviews • Communicate and collaborate with network and non-network providers to achieve accurate and timely benefit determinations • Educate providers on benefit plans and medical policy • Make coverage determinations when services do not meet medical necessity criteria or benefit exclusions require medical evaluation • Make medical necessity determinations on appeals and grievances, ensuring different reviewers conduct each level of review • Provide Medical Director leadership to vendor relationships as directed by the Managing Medical Director • Support organizational accreditation efforts and regulatory review processes, including prior authorization, concurrent review, medical claims review, case management, disease management, pharmacy management, and health education programs • Perform other related duties as directed

🎯 Requirements

• Current unrestricted license to practice as an MD or DO in Pennsylvania • MD or DO degree • Appropriate Board Certification in Psychiatry • Minimum of five years of clinical experience post residency, including both inpatient and outpatient mental health and/or substance use disorder • At least three years of experience in managed care, utilization review, and/or quality management • Currently covered by, or eligible to be covered by, medical liability insurance • Knowledge of current and emerging behavioral health trends, including physical and behavioral health integration models, population health, and alternative payment models • Knowledge of complex and unique issues within the health care industry • Knowledge of health plan regulatory requirements, including CMS, NCQA, and the DOH • Knowledge of current and emerging medical treatment modalities • Familiarity with National Committee for Quality/URAC standards • PC literacy and ability to perform electronic research and respond to electronic requests • Ability to effectively multitask under pressure, meet deadlines, and deliver high-quality work • Demonstrated organizational and time management skills • Proven problem-solving skills and ability to analyze problems and devise appropriate courses of action

🏖️ Benefits

• Approximately 15–20 hours/week • Two holidays/year • Independent contractor arrangement