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Senior Medical Director Behavioral Health-000210

Company: Excellus BlueCross BlueShield
Location: Rochester
Posted on: February 25, 2021

Job Description:

Senior Medical Director Behavioral Health-000210 This position provides clinical leadership for all Behavioral Health (BH) Programs across all lines of business (LOB). Appropriate time is devoted to clinical case review (predominantly appeals) in order to maintain business standards and compliance. The incumbent assists in the identification, creation, and monitoring of Behavioral Health clinical management initiatives and programs. This includes active participation and support in the activities of Member Care Management (UM, CM, DM), and clinical guidelines, medical policies, and quality. The SMD-BH develops and maintains effective clinical relationships with the BH community. Within the Health Plan, the incumbent also works with stakeholders throughout the organization to support the clinical aspects of company BH efforts including (among others) PHE, CAU/PAU, SIU, Legal, Compliance, ACQA/VBP. The SMD-BH has an enterprise-wide, all-LOB role in overseeing the BH Medical Directors of the health plan and supporting BH clinical operations teams to meet or exceed all goals. Essential Responsibilities/Accountabilities: -- Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. -- Responsible for physician review and oversight of all potential adverse determinations including pre-certifications/prior authorizations, concurrent review and appeals/retrospective review (in coordination with LOB VPMA and UM leads). -- Serves as clinical advisor to and educator of medical management staff making sure correct clinical judgment is applied to all medical management determinations -- Acts as subject matter expert on Behavioral Health topics corporate-wide. -- Shares accountability with the Directors of Behavioral Health in meeting NCQA requirements for UM, CM, and operations. -- Oversees, all the BH Medical Directors at the Health Plan by: -- Providing supervision, guidance, development and training of psychiatrists, whether employed or contracted. -- Actively participates in the auditing process of management processes and corrective action team projects for management including interrater reliability testing (IRR) -- Coordinating the MD cross-coverage work schedule to assure that the BH MD's meet all regulatory, compliance and quality standards. -- Provides clinical leadership and responses to BH inquiries and requirements from government agencies (e.g. mental health parity, audits, subpoenas, etc.) -- Serves as the Health Plan Ambassador to the Behavioral Health community for clinical issues and concerns. -- Supports the credentialing and peer review processes -- Works closely with the Corporate Medical Policy team for clinical input and formulation of medical policies and protocols -- Ensures achieving all regulatory and compliance standards, mandates and policies, and is the point of contact for all regulators on clinical issues. -- Keeps up to date on clinically relevant legislative and regulatory mandates and assists corporate compliance and the Director of BH in meeting these requirements. -- Identifies and develops programs to promote integration of Behavioral Health and physical health services to drive improved coordination and continuity across network providers -- Develops and maintains the BH long-term strategy -- Oversees the development of clinical best practices and policies and procedures. -- Provides clinical leadership for the development and implementation of the quality management (QM) plan for Behavioral Health and other specific QM projects and programs. -- Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct and leading to the Lifetime Way values and beliefs. -- Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. -- Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements. -- Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information. -- Regular and reliable attendance is expected and required. -- Performs other duties and functions as assigned by management. -- Minimum Qualifications: -- Medical Doctor or Doctor of Osteopathy, board certified in a psychiatry specialty recognized by the American Board of Medical Specialists or American Osteopathic Board of Medical Specialists -- Boarding in Addiction Medicine, Child Psychiatry, Preventative Medicine is a plus -- Unrestricted, active NY state physician license or ability to attain. -- Minimum of five years of clinical experience -- 3-5 years of Physician leadership with experience in management -- Strong knowledge of managed care and quality -- Physical Requirements: -- Must be able to travel independently between the health plan's regions and sometimes nationally. -- ************ -- The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve. Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce. OUR COMPANY CULTURE: Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits. -- In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Qualifications Education Preferred Doctorate or better in Review Required. Physician or better in Physician. Licenses & Certifications Required Medical Doctor Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

Keywords: Excellus BlueCross BlueShield, Rochester , Senior Medical Director Behavioral Health-000210, Healthcare , Rochester, New York

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