This role is eligible for a $10,000 sign-on bonus for external candidates

Responsibilities:

Provide organizational leadership in the operational areas of care management, utilization review, appeals, quality improvement and related policy and practice initiatives related to Behavioral Health in collaboration with the Corporate Medical Director, Behavioral Health and the Vice President, Utilization Management Physician.

The following responsibilities are in regards to working with enrollees diagnosed with mental illness and substance abuse conditions and their providers:

• Identifies and implements evidence-based practice guidelines throughout the provider network
• Oversees the quality of clinical care for network and non-network providers
• Engages the provider network in Continuous Quality Improvement through the diffusion of practice standards, and through an internal quality assurance program that measures network provider performance against standards of high quality, especially the performance standards embodied in the HEDIS program.
• Reviews and resolves disputes related to the quality of care
• Utilizes a high-performing medical management system that adheres to the terms of contracts and all relevant regulatory requirements. 
• Utilizes evidence based standards in making coverage determinations

Accountabilities:

• Ensures the provision of quality and clinically sound behavioral health care services to all enrollees by associates and providers.
• Serves as medical advisor and manager for all behavioral health clinically related activities.
• Assures that organizations medical policies and procedures adhere to contractual obligations.
• Performs clinical case reviews in conjunction with Medical Excellence Department.
• Maintains familiarity with federal, state and local regulations that may pertain to the medical and clinical operations.
• Provides leadership in the development and implementation of medical policy as it relates to behavioral health management.
• Maintains compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations.
• Manages day-to-day operations and monitors the integration and processing of members to optimize appropriate use of behavioral and physical health services. Participates with Quality Improvement and Medical Excellence in the identification and analysis of medical and behavioral health information in order to develop interventions to improve clinical effectiveness of medical management strategies.
• Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting contractual obligations.
• Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff.
• Trains staff on behavioral health-related issues and provide consultation to staff as appropriate.
• Assists IHC Managers in assessing members’ need for case management services.
• Attends case management meetings and monthly rounds as scheduled.
• Collaborates with the integrated case management team, during scheduled meetings and informally as needed.
• Thoroughly documents all care coordination activity in the member medical record in the electronic medical management system.
• Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports and carries out the ACFC mission and values.
• Other duties as assigned.

Education/Experience:

•  MD.
• 3-5 years Clinical Practice experience.
• Must be licensed to practice in the state of Ohio; additional state licensures may be required for future business 
• Must be board-certified in his/her medical specialty.
• Must be clear of any sanctions by the applicable state or Office of the Inspector General.
• Must not be prohibited from participating in any Federally or State funded healthcare programs.
• Physician licensed to practice medicine and board-certified in general psychiatry with at least 3-5 years combined work experience in mental health and/or substance abuse treatment is preferred.
• A board certified child and adolescent psychiatrist may be substituted with a board certified psychiatrist in general psychiatry having at least five (5) years’ experience providing services to children and youth.