MEDICAL DIRECTOR, OPERATIONS (BEHAVIORAL HEALTH)

California Physicians' Service - Rancho Cordova, CA

Full-time

Rancho Cordova, CA

Insurance Carriers and Related Activities

About the position

The Medical Director, Operations (Behavioral Health) at Blue Shield will play a crucial role in ensuring the organization remains at the forefront of medical, medication, and payment policy, contributing to the advancement of a value-based healthcare system in California. This position involves overseeing psychiatric inpatient concurrent reviews, pre- and post-service utilization reviews, and collaborating with Nurse Care Managers to facilitate effective patient care and resource utilization.

Responsibilities

• Review pre- and post-service behavioral health service requests and render decisions based on member benefits and medical necessity.
• Provide medical decision-making support for behavioral health reviews requiring authorization or review.
• Engage in telephonic physician-to-physician discussions regarding current members in various levels of care.
• Train utilization and care management staff, including physicians, psychologists, nurses, and social workers.
• Perform clinical reviews to support utilization management and fraud waste and abuse evaluations.
• Participate in quality management functions to improve care quality and outcomes for members.
• Contribute to projects and committees as necessary.

Requirements

• Medical degree (M.D./D.O.) with 12 years of experience, including a minimum of 5 years in behavioral health clinical experience, preferably in a hospital setting.
• Unrestricted California State Medical License.
• Board Certification in Psychiatry or related ABMS category.
• Minimum of 5 years of active clinical behavioral health practice with recent inpatient psychiatric hospital experience.
• 3-5 years of Health Plan experience in Medicare Advantage utilization management or quality improvement activities is preferred.
• Ability to work independently and resolve issues in ambiguous situations.
• Strong communication skills to motivate and guide others effectively.
• Collaboration skills to work within diverse teams.
• Understanding of managed care organization and financial metrics.
• Knowledge of behavioral health services and conditions, with rapid decision-making abilities.
• Experience with CPT coding, medical claims review, and hospital billing.
• Deep knowledge of MHPAEA, SB855, and regulatory compliance requirements.

Nice-to-haves

• Experience in managed care supporting utilization management of all levels in behavioral health.