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Behavioral Health Core Medical Director

Company: MetroPlus Health Plan
Location: New Haven
Posted on: January 9, 2021

Job Description:

About NYC Health + HospitalsMetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus' network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.--Position OverviewResponsible and accountable to the Deputy Chief Medical Officer for helping to manage health plan behavioral health quality and costs and assuring appropriate health care delivery. The Associate Medical Director serves in policy, operational and strategic capacities. The Associate Medical Director has over all accountability for behavioral health services for mainstream plan enrollees. This is a broad function that includes day to day operations, data and reporting design and high-level strategy, planning and policy involvement.Job Description

  • Support the maintenance of clinical protocols and policies to enhance the quality of medical necessity decision-making, incorporating input from the clinical review team, operations, and other medical operations leads such as the OMH / OASAS State Medical Directors forums.
  • Support reporting and regulatory needs for the utilization review function for quality and regulatory purposes as necessary
  • Conduct analyses to identify trends and patterns suggestive or indicative of:
  • Inappropriate, unreasonable, medically unnecessary care; inappropriate transfers; and Insufficient, poor documentation or patterns of failing to provide medical records.
  • Chair the Case Management / Utilization Management Mainstream quarterly Subcommittees.
  • Supervise retrospective review of claims to identify practice patterns that could be improved to reduce costs and improve care.
  • Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and outcome decisions, including feedback on alternate treatment based on medical necessity criteria
  • Develop a working familiarity with applicable regulatory and accreditation requirements as well as workflows in place to ensure to meet the prescribed standards.
  • Oversee the development of evidence based clinical best practices, policies, and practices.
  • Participate as a member of Interdisciplinary Care Teams (ICT) that ensures an integrated model of care approach for the designated population(s); work with other medical representatives of ICTs to ensure a consistent and high value approach to team processes
  • Sole authority and responsibility for assuring that clinical adverse determinations are based on medical necessity.
  • Work collegially with the Senior Director of BH to identify trends, problems, and opportunities, including conduct root cause analysis.
  • Shares accountability with Senior Director of BH in meeting NCQA requirements for UM CM and Operations.
  • Work closely with the corporate medical policy team for clinical input and formulation of BH policies and protocols.Minimum Qualifications
    • Board Certified Adult Psychiatrist, Child, and Adolescent Board Certification required
    • Active New York license or certification to practice medicine without restriction required (MD or DO required)
    • Minimum of 5 years of experience working in BH managed care setting and/or BH clinical setting overseeing Care Management function
    • Appropriate training and expertise in general psychiatry and or addiction disorders required.
    • Experience with governmental programs including Medicaid, Medicare, Long term care; additional experience in commercial/ MSO/ASO is a plus.
    • Administrative experience on a hospital committee, in a medical group or for an insurer preferred.
    • Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment Protocols required.
    • Knowledge and understanding of managed care principles, industry evolution, physician reimbursement, and human resource management required.Licensure and/or Certification Required
      • Current unrestricted license to practice medicine in the State of New York.Professional Competencies
        • Integrity and Trust
        • Customer Focus
        • Functional/Technical skills
        • Written/Oral Communication

Keywords: MetroPlus Health Plan, New Haven , Behavioral Health Core Medical Director, Healthcare , New Haven, Connecticut

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