Director- Senior Medical Director Behavioral Health

• Direct, lead and provide professional oversight for medical management activities related to utilization management, peer clinical reviews, case management, disease management, and quality management activities. Support collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals and to ensure that medical policies, procedures and the activities/actions of the division on behalf of the corporation are consistent with the standards of good medical practice in the community.
• Responsible for overseeing the Behavioral Health Programs to ensure operations in compliance with clinical guidelines, contractual, accreditation and regulatory requirements for all business segments.

REQUIRED QUALIFICATIONS

• 5 years of experience in a behavioral health clinical setting
• 5 years of experience in physician leadership role, including quality review, utilization review and other managed care functions
• Experience in developing and executing operational strategies that result in increased service levels, clinical efficiencies and improved quality of care

Required Education

• Medical Degree

Required Licenses

• Active, current, and unrestricted license to practice medicine in the State of Arizona  (a state in the United States).

Required Certifications

• Board Certification in Psychiatry

PREFERRED QUALIFICATIONS

• 5 years of experience in psychiatry

ESSENTIAL job functions AND RESPONSIBILITIES

• Provide direction, support and medical expertise and oversight to areas within the Health Services Division such including utilization management, peer clinical review, quality management, case management, medical claims review, medical risk assessment, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical underwriting, medical claims reconsideration and retrospective review.
• Serve as the Behavioral Health lead and liaison on community Behavioral Health issues
• Develop and implement Behavioral Health programs, initiatives and policies to improve member outcomes, care coordination, community response and ensure compliance with applicable BCBSAZ benefit plans, state, federal and accreditation guidelines.
• Develop and implement long-term goals and objectives to achieve the successful outcome of the Behavioral Health program
• Ensure that program activities operate within the policies and procedures of the organization
• Provide consultative services throughout the corporation, including for the Marketing, Sales, Legal, Actuarial, Network Management, Internal Audit, Finance, and Claims Divisions.
• Communicate with customers regarding their difficult and costly cases, including recommendations and showing the impact of BCBSAZ interventions.
• Provide peer clinical review activities and conversations as clinically appropriate including when requested for pre-service medical necessity denials.
• Seek to improve department/division efficiency through effective use of information system tools and processes to reduce healthcare costs, increase quality of care and service, and reduce administrative expense.
• Participate in the development of new products and benefit design.
• Develop, review, and implement medical policies and other medical decision making policies or procedures
• Represent BCBSAZ at professional organizations and acts as liaison with individual health care professionals and supports collaborative relationships with physicians and hospitals.
• Participate in various clinical peer committees including, but not limited to, the Clinical Quality Improvement Committee, Credentialing Committee, Focused Provider Review and Medical Policy Panel.
• Participate in medical management strategic planning in evaluating utilization, quality, national and local trends and identifies interventions to optimize the utilization of resources and the delivery of high quality health care services.
• Participate in the appeals and grievance processes to assure timely and accurate responses to members and providers
• Provide written information to members and providers through letters and articles in member and provider newsletters and other publications.
• Work to ensure productive relationships with all customers, employers, members, and providers to ensure members receive the appropriate health care in the most appropriate setting with the best value in health care.
• Provide leadership to staff and other professionals through clinical excellence, professional behavior and innovative thinking.

OVERALL

• Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.
• Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
• Maintain effective working relationships to ensure teamwork in achieving corporate goals.
• Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZ goals and ensure future success.
• Coordinate activities between multiple divisions to achieve desired results.
• Volunteer within the community to help BCBSAZ give back to community charitable efforts.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Performs all other duties as assigned.