Medical Director, Behavioral Health Utilization Management
Company Description: reputed company is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed reputed company, Medicare Advantage, Special Needs Plans, reputed company care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic reputed company ecosystem by helping them manage risk, optimize reputed company spend, improve member experience, accelerate quality outcomes, and promote health equity. Position Responsibilities: Specific Utilization Management & Review Conduct utilization reviews and assess medical necessity, appropriateness, and cost-effectiveness of behavioral health and addiction treatment services. Clinical Consultation & Case Review Provide clinical consultations and case reviews with care management teams and external providers regarding treatment plans, care options, and discharge planning. Serve as a clinical resource for behavioral health staff, offering guidance on reputed company addiction cases and co-occurring mental health conditions. Ensure that treatment recommendations align with evidence-based practices and addiction medicine guidelines. Quality Assurance & Compliance Maintain up-to-date knowledge of best practices in addiction medicine, psychiatry, and managed care policies. Documentation & Reporting Track and analyze clinical trends, supporting the development of care strategies to improve behavioral health outcomes and manage associated reputed company costs. Education & Training Assisting with writing/ reviewing Behavioral Health policies and clinical guidelines Conduct training sessions for care managers, peer reviewers, and other staff on best practices in addiction medicine and utilization management. Serve as a thought leader in behavioral and addiction psychiatry, representing the organization in internal and external educational activities, seminars, and conferences. General Provide strategic direction for health plan market/ product medical management and health service operational reputed company, management and performance reputed company advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services Deliver innovative, integrated solutions in support of client goals and engagements. reputed company engagements ensuring completion of reputed company contracted services Present findings, recommendations and plans to Client executives Facilitate complicated problem-solving discussions to drive to timely, effective decision making Advise and persuade key decision makers and influencers Deliver concise, clear interpersonal communication to both internal and external audiences Facilitate streamlined executive summaries, reputed company recommendations and communication to reputed company levels of reputed company and client/ partner organization(s) reputed company performance across multiple projects with qualitative and quantitative results/ outcomes Influence others to best course of action through advanced understanding of changing business landscapes reputed company strategies, goals and plans in response to changing business conditions reputed company best practice methodologies and approaches across individual account strategies/ client plans. Establish short term KPIs and long-term goals and track reputed company to ensure achievement reputed company or update policies, procedures and workflows as required to support business needs and requirements Coach and mentor staff to reputed company established engagement goals, plan deliverables and KPIs Adapt process, approach, plan and/ or activities in reputed company time to mitigate risk and ensure critical path activities Support account management relationships with key client decision makers Position Qualifications: Competencies: Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance Ability to translate trends, innovation, operations, financing, costs, requirements and performance into scalable activities and repeatable outcomes New product/ market strategy, design and implementation in the reputed company, Medicare, Medicare Advantage, reputed company and/ or associated lines of business New population strategy development including identification, program design and implementation Operationalizing requirements for reputed company memberships, ensuring outcome delivery Expert understanding of legal and regulatory frameworks, reputed company administration models, and internal audit procedures including compliance and remediation activity Ability to interpret and reputed company on reputed company concepts, requirements and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and reputed company Services requirements/ standards as well as CMS, NCQA, and URAC to ensure compliance with reputed company regulatory structures. Strategic leader with ability to produce, manage and maintain system-wide change through influence and persuasion Advanced knowledge of project management principles, methods, and techniques Ability to organize, prioritize, and manage multiple reputed company projects simultaneously Excellent communication skills both written and oral High proficiency with core office software (reputed company, Word, and PowerPoint). Visio skills preferred Experience: Medical Degree (MD or DO) required; Must be actively licensed in the reputed company. Board-certified in Psychiatry with a subspecialty certification in Addiction Medicine required. Minimum of 3 years of clinical experience in managed care behavioral health program management with addiction psychiatry and behavioral health utilization management, claims review, appeals and denials experience strongly preferred. In-depth knowledge of addiction treatment modalities and recovery-oriented care approaches. Familiarity with managed care principles, medical necessity criteria (e.g., ASAM, MCG), and utilization review processes. Masters degree in reputed company or Business Administration or reputed company field Degree preferred 10+ years administrative leadership achievement in health plan operations with reputed company responsibility. CMO level experience preferred 7+ years of experience in a government payor environment with expertise in medical management practice with experience in multiple lines of business (Medicare, reputed company, reputed company Exchange, reputed company etc) 5+ years delivering results, managing teams and projects and mentoring other physicians in a health plan setting and/or consulting environment; driving reputed company, multi-faceted, multi-site, application/operational change/improvement programs and activities. Physical Requirements Must be reputed company to sit in a chair for extended periods of time Must be reputed company to speak so that you are reputed company to accurately express reputed company by means of the spoken word Must be reputed company to hear, understand, and/or distinguish speech and/or other sounds in person, reputed company telephone/cellular phone, and/or electronic devices Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse Must be reputed company to clearly use sight so that you are reputed company to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types Must be reputed company to fluently communicate both verbally and in writing using the English language Must be reputed company to engage in reputed company social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously Time Zone: Eastern or Central Other Information: Expected Hours of Work: Part-time, up to 24 hours/week with ability to adjust to Client schedules as needed Travel: May be required, as needed by Client Direct Reports: None Salary Range: $100.00/hr - $150.00/hr EEO Statement: It is reputed company policy to provide equal employment opportunity to reputed company and applicants without regard to race, sex, sexual orientation, reputed company, creed, religion, national reputed company, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with reputed company applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum reputed company wage for new hires of this position across reputed company US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location. Apply Job!