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Clinical Director of Behavioral Health Operations
4 weeks ago
Job Summary
The Blue Shield of California Medical Management team is dedicated to ensuring that our organization remains at the forefront of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system in California.
The Medical Director, Operations (Behavioral Health) will report to the Senior Medical Director, Behavioral Health. This role will involve reviewing pre- and post-service behavioral health service requests and rendering decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP (Federal Employee Program) medical policy, as well as legal and regulatory requirements.
Key Responsibilities
- Medical decision-making and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely discharges
- Train BSC utilization and care management staff, which may include physicians, psychologists, nurses, social workers, and others as needed
- Perform clinical reviews to support utilization management and fraud, waste, and abuse case evaluations
- Participate with the quality management function in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes for our members
- Participate on projects and committees, as necessary
Requirements
- A Medical degree and 12 years' experience, including a minimum of 5 years' behavioral health clinical experience, preferably including hospital experience
- Unrestricted California State Medical License required
- Board Certification in one of ABMS categories, preferably in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Association (AOA)
- A minimum of 5 years of experience in active clinical behavioral health practice with active recent inpatient psychiatric hospital experience (within the past five years) is desirable
- A minimum of 3-5 years of Health Plan experience in Medicare Advantage utilization management, case review, and/or quality improvement activities in a managed care setting is preferred but not required for this position
Preferred Qualifications
- Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications
- Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to behavioral, project management, and more
- An ability to understand overall managed care organization, business strategies, and financial metrics; well-versed with most areas of behavioral health services and conditions, show ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issues
- Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency
- Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855, and all regulatory and compliance requirements
About the Ideal Candidate
The ideal candidate will be a highly talented psychiatrist with managed care experience supporting utilization management of all levels in behavioral health.
