Leading health plan seeks a Medical Director - Psychiatry, to oversee the utilization management plan for various California affiliated health plans. The Medical Director - Psychiatry should be and M.D. or D.O. with a speciality in psychiatry, and an active California medical license.
Requirements for the Medical Director Psychiatry:
• M.D. or D.O. licensure in California, ABMS board certification in psychiatry
• Completion of psychiatric residency in the U.S. or Canada, approved by the ACGME
• 5+ years post residency clinical psychiatric care experience
• Experience in managed care, health plans
Responsibilities for the Medical Director - Psychiatry:
• Develop and implement a Utilization Management program and action plan.
• Manages UM practices including over and under utilization, evaluating UM practices and criteria.
• Provide direct support to UM and clinical care teams.
• With corporate clinical team implements clinical practice standards and policies and participates in management of activities.
• Develop, implement and interpret medical policy, technology assessments, and medical necessity guidelines.
• Develop working relationships with practitioners, provider facilities, treatment programs, conferring directly with psychiatrists and other practitioners regarding the care of patients with severe, complex, and/or treatment resistant illnesses.
• Ensures that contract requirements, accreditation standards (e.g. NCQA), state policies and federal policies are implemented specific to each client.
•Work with teams on continuous quality improvement to ensure ongoing compliance in utilization and case management.
• Participate in and maintain the integrity of the appeals process, both internally and externally.
• Investigate adverse incidents and quality of care concerns.
• Participate in preparation for NCQA and URAC certifications.
• Develop and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead senior medical director, and quality improvement staff