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Medical Director - Behavioral Health

Company: Horizon Blue Cross Blue Shield of New Jersey
Location: Newark
Posted on: October 11, 2018

Job Description:

Job Summary:

This position is accountable for development, implementation and ongoing assessment of the behavioral health components of the medical management program of the enterprise, as well as daily supervision and oversight of those activities. The position will additionally provide leadership support as needed, for network management and contracting activities. Provides behavioral health medical management direction with regard to tactical and strategic planning. Assures the implementation of enterprise policies and procedures, and the achievement of business plan goals in areas of accountability.

Responsibilities:


  • Provides leadership, direction and support for the behavioral health clinical team involved in the implementation of the components of the medical management program.
  • Assures development of performance goals and targets for team, the identification of issues impacting performance, and development and implementation of corrective action.
  • Assures compliance with regulatory and accreditation standards.
  • Participates with informatics and finance in development and analysis of behavioral health management reports.
  • Assures development and implementation of UM policies and procedures (mental health and substance use disorder policies).
  • Participates in hospital, physician and ancillary network initiatives.
  • Recruits, supervises and assures professional development of clinical staff.
  • Functions as a resource for resolution of provider and member appeals, complaints and grievances.
  • Participates in internal and external committee activity as required.
  • Supports and participates in quality management and process improvement activities.
  • Serves as an Enterprise representative to the external medical community.
  • Serves as a resource for resolution of difficult cases, benefit interpretation, high profile cases, and risk management issues.
  • Represents the Health Plan when interacting with Provider Partners, External Clients, Behavioral Health professional organizations or other external entities.
  • Assures the Health Plan's management of behavioral health benefits are aligned with clinical best practices and all applicable State and Federal requirements such as Federal Mental Health Parity.

    Knowledge:


    • Requires excellent understanding of the principles and concepts of managed care.
    • Requires knowledge of Utilization Management, Continuous Quality Improvement, Complex Case Management programs and principles of prevention and wellness.
    • Requires knowledge of patient appeals process. Requires broad clinical knowledge and understanding of current health care issues.
    • Knowledge of regulatory and accreditation standards.
    • Knowledge of product design and benefit structure.
    • Knowledge of best in class behavioral health care from a treatment and outcomes perspective.
    • Knowledge of optimal systems of care delivery for behavioral health.

      Skills and Abilities:


      • Requires broad clinical skills to understand medical issues and to discuss them with attending physicians.
      • Requires the ability to interpret medical policy and provide guidance to others.
      • Requires the ability to exercise independent judgment in making medical necessity decisions
      • Requires strong leadership skills.
      • Requires strong project management skills.
      • Requires good communication and presentation skills.
      • Requires analytical skills to evaluate data from various sources, identify trends/issues and to develop recommendations for senior management.

        Education:


        • MD or DO degree.

          Experience:


          • Requires a minimum of five years clinical experience with five years' experience in a medical management leadership role.
          • Requires demonstrated success in implementing managed care policies, programs or initiatives. Requires demonstrated success in improving HEDIS performance.
          • Requires demonstrated success in developing and implementing Complex Case Management and wellness programs.

            Additional licensing, certifications, registrations:


            • Active Unrestricted MD License Required; NJ License Required.
            • Requires board certification in Psychiatry with specialization in Addiction Medicine preferred.

              Travel % (If Applicable):


              • 20% travel within the state of New Jersey

                This role may also be used in other areas of HCM to partner with other value based programs.

                Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

                Keywords: Horizon Blue Cross Blue Shield of New Jersey, Newark , Medical Director - Behavioral Health, Healthcare , Newark, New Jersey

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