Physician - Medical Director - Behavioral Health
Spectrum Health
.00 Medical and Health Services Managers Spectrum HealthUS
2d ago

Spectrum Health is a not-for-profit system of care dedicated to improving the health of families and individuals. We are nationally recognized for our quality and clinical excellence as an integrated health system.

We attract and retain the best and brightest talent diverse individuals whose words and actions demonstrate our values of compassion, excellence, integrity, respect and teamwork.

In return, Spectrum Health provides opportunities for you to challenge yourself and seek out new ways to offer better service and care.

Position Summary

This position is critical to Priority Health's mission of improving the health and lives of the people we serve in collaboration with the health plan’s provider partners and major delivery systems.

Provide comprehensive behavioral health care management and clinical oversight for Priority Health’s Behavioral Health clinical and utilization management programs.

Develop and drive innovative behavioral health strategies that focus on improving health and managing costs for all lines of business.

Essential Functions :

  • Provide clinical leadership and guidance for behavioral health case management and utilization management programs, including authorizations, denials and appeals.
  • Conduct peer to peer case reviews for medical necessity determination as necessary.
  • Recommend, develop, implement and interpret behavioral health medical policy including medical necessity criteria, clinical practice guidelines and new technology assessments.
  • Develop and enhance relationships and clinical partnerships within the behavioral health provider community.
  • Collaborate as necessary to assure compliance with all regulatory programs impacting behavioral health, including National Committee for Quality Assurance (NCQA), CMS, State Medicaid, MHPAEA, State Mental Health Code, 42 CFR Part 2 and Mental Health Parity requirements.
  • Provide clinical expertise in the evaluation of behavioral health quality improvement, reimbursement methodology, fee review, claim payment, and fraud and abuse.
  • Be the thought leader on innovative behavioral health strategies to drive better care, improve health, and lower cost.
  • Engage in demonstrating the value proposition for behavioral health clinical program through quantitative analytics, ROI an evidence-based data.
  • Basic Qualifications :

    Education - Medical Degree (MD or DO) from a medical school approved by the Council on Medical Education of the American Medical Association or an osteopathic school approved by the Council for the American Association of Colleges of Osteopathic Medicine

    Experience - 3 years of experience typically gained through skills / knowledge / abilities in a clinical setting, along with 3 years of experience in managed care

    Preferred Qualifications :

  • Experience - Proven experience and evidence of success in effective physician communication and education skills; evaluation of evidence-based standards of care including the ability to critically analyze data;
  • clinical program development and assessment; physician and clinical practice partnership development and application of utilization management skills and strategies

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