HEALTH PLAN MEDICAL DIRECTOR, BEHAVIORAL HEALTH
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The French Group has been retained to fill a newly created Behavioral Health Medical Director role for one of our national health plan clients. This is an ideal role for a clinician seeking to transition to administrative medicine as prior health plan experience is not required.
The Medical Director will be responsible for the following:
- Daily utilization management activities for all lines of business including Medicare.
- Support provider relations activities
- Assist in the development and implementation of medical policy and interventions to improve the quality of care and outcomes.
- Participate in the attainment of quality management goals as established by all external agencies.
- Supervise, review and approve or deny requests for medical necessity decisions according to medical policy.
- Interpret medical policy criteria for Health Services associates to facilitate the application of policy in pre-certification, concurrent review and case management.
- Initiate dialogue with providers, as necessary, to resolve differences in opinions concerning utilization management.
- Review and make decisions on provider appeals.
- Make recommendations (based on daily activities of evaluating members’ care) about medical policy, clinical criteria and administrative process.
- Serve on various committees to evaluate recommendations for changes.
- Work with the medical community to assist in the development and maintenance of a strong, quality network of providers.
- Support provider relations and risk contracting through education, provider visits and problem resolution.
- Visit targeted providers for recruitment, as well as performing proactive provider visits as scheduled.
- Work with quality management and medical cost analysis staff to identify trends in treatment and outcomes by interpreting various data.
- Review provider and member complaints, assist in resolution, and make recommendations for changes.
- Utilize clinical expertise to assist in the development of care improvement programs to improve health outcomes for the member population.
- M.D with active, unrestricted FL medical license
- Current Board Certification in Psychiatry
- 5+ years of clinical experience and a strong working knowledge of managed healthcare required.
- Experience with government programs, particularly Medicare, preferred
- Demonstrated success implementing utilization tools/techniques and experience with physician behavior modification required
- Participation in hospital managed care or medical practice UM committees preferred
Tricia French, RN, BSN firstname.lastname@example.org 757-362-0202