Medical Director, Behavioral Health with certification in psychiatry

Are you a dedicated and experienced medical professional with a passion for quality improvement and healthcare administration? We are seeking a self-motivated and detail oriented Medical Review Director to lead our team in ensuring the highest standards of medical necessity determinations and clinical metrics analysis.

You may be a great match for this role if you are a versatile board-certified psychiatrist with management experience in the areas of behavioral health and addiction medicine. We re looking for candidates who are versed in leading multidisciplinary teams in developing and standardizing behavioral health programs and quality measures and are skilled in providing multidisciplinary staff supervision with a minimum of five years of clinical experience in a variety of managed care treatment settings. Work experience within the insurance industry is preferred but not required.

In addition to the job responsibilities below, this Medical Director will be responsible for:

• Medical necessity reviews and appeals
• Conducting peer to peer reviews
• Medical supervision of utilization management and case management staff
• Reporting quality of care concerns
• Participation in medical policy development
• Participation in credentialing activities for incoming providers and providing leadership in improving treatment outcomes

Job Responsibilities

• Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines.
• Analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiatives.
• Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews.
• Lead and serve on various committees in order to accomplish medical utilization, cost and quality objectives of BCBST.
• Willingness to travel within the State of Tennessee and nationally.

Job Qualifications

Education

• Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Tennessee required. *However, this requirement can be waived for jobs where the totality of the incumbents duties and responsibilities are restricted to the performance of administrative duties only.
• Completion of a MD Residency training program in Psychiatry.

Experience

• 5 years - Clinical experience required
• 2 years - Inpatient or hospital-based treatment experience required
• 5 years - Healthcare administration, including UM experience required
• 3 years - Experience in dual Medicare/Medicare SNP programs required

Skills\Certifications

• Board Certification in psychiatry (a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists).
• Ability to conceive and deliver innovative solutions
• Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
• Outstanding negotiation, presentation, and facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)
• Excellent oral and written communication skills
• Ability to lead and motivate cross-functional, interdisciplinary teams to achieve tactical and strategic goals.
• Substantial knowledge of mental health and chemical dependency services and practices, including treatment techniques, discharge planning and transitions of care.