Medical Director (Behavioral Health)
Medical Director (Behavioral Health)
Department(s): Medical Management
Reports to: Chief Medical Officer (CMO)
FLSA status: Exempt
Salary Grade: V - $221,400 - $331,200
The Medical Director for Behavioral Health (BH) is responsible for clinical oversight and management of CalOptima's behavioral health activities including, case management, utilization management, quality management, and contracted services.
- Provides strategic direction for the Behavioral Health Department.
- Provides quality oversight and lead the quality efforts for Behavioral Health.
- Develops and implements medical policies for Behavioral Health.
- Provides direction and control of current medical practices for Behavioral Health ensuring that medical personnel for the plan follow medical protocols and rules of conduct.
- Ensures that medical decisions regarding behavioral health are rendered by qualified medical personnel, unhindered by fiscal or administrative management.
- Oversees reporting and profiling of behavioral health providers.
- Ensures the appropriate and timely use of criteria and guidelines in the administration of behavioral health treatment.
- Ensures that assigned patients are provided behavioral health services and necessary medical attention at all locations.
- Works with the Contracting department to ensure a full and appropriate primary and specialty behavioral health care provider network for members.
- Consults on written protocol for behavioral health providers to ensure adherence to standards and quality of care. Coordinate professional interactions amongst practitioners and lend assistance toward correcting any deviation from standards. Develop relationships with directly contracted behavioral health providers.
- Participates in the quality management program for behavioral health providers which includes protocol, procedures, oversight, and training in the following areas:
- Provider selection
- Quality assessment studies
- Peer review activities
- Referral management
- Pre-admission authorization
- Prospective, concurrent and retrospective review
- Utilization review reporting and evaluation
- Case management
- NCQA accreditation
- Reviews State and Federal mandated benefits to ensure CalOptima Behavioral Health is in full compliance through its providers.
- Ensures the privacy and security of Protected Health Information (PHI) as outlined in CalOptima's policies and procedures relating to HIPAA compliance.
- Any other duties as required to ensure the plan operations are successful.
- Other projects and duties as assigned.
Knowledge & Abilities:
- Manage a large point of service network of providers.
- Develop and implement appropriate medical service contracts and monitor compliance.
- Plan, organize, and direct utilization review, quality management, case management, health education, and grievance activities.
- Ensure appropriate and cost-effective medical care and services to members not covered by a contracted health plan.
- Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the general public.
- Communicate clearly and concisely, both verbally and in writing.
- Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education:
- Current, valid, unrestricted California Physician and Surgeon's License with Board certification in Psychiatry required.
- 5+ years of Medical Administrative experience required.
- Utilization Management experience with expertise in Medi-Cal managed care and Medicare required.
- Sub-specialization or additional training and experience in substance use disorder with understanding of American Society of Addiction Medicine (ASAM) Levels-of-Care with the County Organized Delivery System Drug Medi-Cal (ODS - DMC) preferred.
- Additional training with children including understanding of County Levels-of-Care, Regional Center, and Applied Behavioral Analysis for Autism Spectrum Disorder (ASD), Intellectual Disabilities and other non-ASD diagnoses preferred.
- Expertise in medical program design preferred.
- Electronic Health Records (EHR) typically used by Behavioral Health (BH) provider, Medical Providers, Hospitals and Managed Care.
- Administrative practices and procedures including but not limited to quality assessment and improvement, utilization review, peer review, credentialing, and risk management.
- Rules regulations, policies, and standards related to managed care, including California Department of Health Care Services (DHCS), and California Department of Managed Care Services (DHMS)
- Effective supervision and organization.
- Pay for Value reimbursement and other innovative BH provider reimbursement that focuses on quality.
- Medi-Cal services coordination with Local Education Authorities (LEA)
- Methods, techniques, practices, principles, and literature in Psychiatry including psychopharmacology for formulary and non-formulary medications, other psychiatric treatments including innovative / experimental treatments.
- Methods, techniques, practices, principles, and literature in the broad field of medical sciences and an overview of the highly specialized techniques, procedures and equipment used in the medical or surgical specialists.
EEO Statement: CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
ADA/Accommodation Statement: If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations with 72-hour notice by contacting Human Resources Disability Management at 657-900-1134.
Job Location: Orange, California, United States
Position Type: Full-Time/Regular
To apply, visit https://caloptima-hr.silkroad.com/epostings/index.cfm?fuseaction=app.jobinfo&jobid=3238
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