Job Description

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Behavioral Health will report to the Senior Medical Director, Behavioral Health. In this role you will have core responsibilities in the areas of behavioral health concurrent review, pre- and post-service utilization review, and collaboration with Clinical Care Managers. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Review concurrent, pre- and post-service behavioral health service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP (Federal Employee Program) medical policy, as well as legal and regulatory requirements
• Medical decision and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely discharges
• Engage in telephonic peer-to-peer discussions regarding current members in various levels of care or who may be receiving other specialized services. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers
• Train BSC utilization and care management staff which may include physicians, psychologists, nurses, social workers, and others as needed
• Perform clinical reviews to support utilization management and fraud waste and abuse case evaluations
• Participate with the quality management function in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes for our members
• Participate on projects and committees, as necessary

Your Knowledge and Experience

• Minimum 5 years direct patient behavioral health clinical care experience post residency required
• Medical degree (M.D./D.O.)
• Completed residency in Psychiatry
• Maintain active, unrestricted California Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required
• Maintain Board Certification in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP) required

Preferred Qualifications:

• Recent inpatient psychiatric hospital experience (within the past five years)
• Recent substance use disorders treatment experience (within the past five years)
• Well-versed with most areas of behavioral health services and conditions
• Show ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issues
• Experience with CPT coding, medical claims review, hospital billing, and reimbursement
• Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855 and all regulatory and compliance requirements
• Managed care experience supporting utilization management, case review, and/or quality improvement activities in behavioral health
• Experience with ASAM, LOCUS, CALOCUS, and WPATH

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