Behavioral Health Core Medical Director
Company: MetroPlus Health Plan
Location: New Haven
Posted on: January 9, 2021
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
- 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
- Conduct analyses to identify trends and patterns suggestive or
- 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
- Supervise retrospective review of claims to identify practice
patterns that could be improved to reduce costs and improve
- 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
- 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
- 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
- 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
- Board Certified Adult Psychiatrist, Child, and Adolescent Board
- 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
- 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
- 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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