Medical Director – Behavioral Health

🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $212k - $344.5k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Capital Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1938

⚕️ Healthcare Insurance

💸 Finance

👥 B2C

Healthcare Insurance • Finance • B2C

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

• Provides physician insight and collaborates in the development and evolution of Capital’s BH program and strategy. • Participates in and advises Capital committees (e.g., Quality Improvement Committees, Utilization Management Committees, Member Safety Committee) on BH topics and strategy development. • Provides oversight, guidance, consultation and expertise to Capital’s BH clinical operations, including utilization management, care management, complex case reviews and clinical rounds. • May provide limited cross-coverage support for Care Management and Utilization Management activities, including consultation on complex cases, clinical rounds, or care coordination initiatives, as business needs require. • Reviews data to identify trends relating to BH clinical operations and provides feedback on medical necessity criteria and/or medical policies underlying BH utilization management decisions and subsequent appeals. • Collaborates cross-departmentally (internally) and with key external stakeholders, including Capital’s network providers, to drive Triple Aim outcomes. • Provides BH expertise to inform clinical programs and services that drive quality and HEDIS, STAR, and CAHPS improvement. • Works directly with Capital network providers and internally within Capital to champion provider practice transformation in support of Capital’s value-based delivery models. • Establishes relationships and regular touchpoints with key BH network providers to collaborate on opportunities to improve health outcomes for Capital’s members. • Provides clinical leadership to the development and evolution of strategies to improve access and availability of BH care and services to Capital members, including physical and BH integration models (collaborative care models) and integrated care management programs among others. • Provides clinical leadership to the development and executes on the strategic direction for Capital’s BH strategy, including any vendor-supported programs and services. • Helps to promote Capital’s clinical vision and programs in the local medical community and within Capital’s 21-county service area. • Reviews and analyzes data to drive that transformation in improving member health, experience of care, and medical costs. • Supports organizational accreditation efforts and regulatory review processes, including participation in key committees and quality improvement activities. • Performs activities in compliance with all applicable regulatory entities including NCQA, CMS, PID, and DOH, among others. • Performs other related duties and assignments as requested and directed.

🎯 Requirements

• A minimum of five years of clinical experience, post residency, including both inpatient and outpatient mental health and/or substance use disorder. • A minimum of 8 years of experience in health care with an emphasis on analysis and process optimization. • Managed Care Organization and/or health insurance plan experience preferred. • Knowledge of current and emerging BH trends, including physical and behavioral health integration models, population health, and alternative payment models. • Knowledge of and prior involvement with complex and unique issues within the health care industry. • Knowledge of health plan regulatory requirements, including CMS, NCQA, and the DOH. • MD or DO Degree, as well as appropriate Board Certification. • Current unrestricted license in Pennsylvania as an MD or DO. • Currently covered by, or eligible to be covered by, medical liability insurance. • Current valid Pennsylvania drivers’ license.

🏖️ Benefits

• Medical, Dental & Vision coverage • Retirement Plan • Generous time off including Paid Time Off • Holidays • Volunteer time off • Incentive Plan • Tuition Reimbursement