HARP Medical Director
Company: MetroPlus Health Plan
Location: Newark
Posted on: January 10, 2021
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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 forbehavioral health services
for HARP 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* VSupport
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 the use of integrated care models such as
collaborative care model for treating conditions in primary care.*
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 HARP 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.* Promote medical necessity determinations that consider
level of need as well as environmental factors, available
resources, and psychosocial rehabilitation standards.* Develop a
working familiarity with applicable SUD regulatory standards based
on the OASAS LOCADTR tool.* Understanding of specialized expertise
for assessment, treatment and management of special population,
including older adults, transition age youth (TAY), individuals
with co-occurring disorders, individuals experiencing first episode
of psychosis (FEP) individuals with SMI and criminal justice or
assisted outpatient treatment (AOT) involvement and individuals
with SMI and /or functionally limited SUDs.* 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 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.* Perform other duties as
needed and assigned by the Chief Medical Officer/ DCMOMinimum
Qualifications* Board Certified Adult Psychiatrist with 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 activities* 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, Newark , HARP Medical Director, Healthcare , Newark, New Jersey
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