Behavioral Health Medical Director

Position Purpose: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Key Details: Must be a Board Certified Psychiatrist and licensed in either California or Oregon.

Highly preferred the candidate lives in the Pacific Time Zone. Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.

Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. Supports effective implementation of performance improvement initiatives for capitated providers.

Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.

Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.

Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.

Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate.

Assists in the development and implementation of physician education with respect to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.

Identifies clinical quality improvement studies to