Medical Director- Behavioral Health

Reporting to the Sr. Medical Director, the Medical Director – Behavioral Health is responsible for clinical oversight and management of the IEHP Behavioral Health activities and case management, and participates in quality management, utilization management (UM) and grievance and credentialing functions for the Behavioral Health program. In partnership with Health Services Senior Leadership, the Medical Director oversees the inpatient/concurrent review process, care integration efforts and all levels of behavioral health care provided to IEHP members. The Medical Director coordinates care with the County Mental Health Plans that are responsible for the care of the population with a Serious Mental Illness (SMI) and the County Alcohol and Drug Program as well as all IEHP community and provider partners.

Position Responsibilities

  • Provides overall clinical leadership and develops and implements clinical policies for the IEHP Behavioral Health Program. This includes delivery of mental health services, substance use services, medication management, and coordination of behavioral health services and primary care.
  • Provides direction of current clinical practices for behavioral health services. Ensures that qualified medical/clinical personnel render clinical decisions regarding behavioral health, unhindered by fiscal or administrative management, and consistent with regulatory requirements and UM guidelines.
  • Leads Behavioral Health quality improvement efforts while helping to manage health plan medical costs, assuring an appropriate and efficient health care delivery system for IEHP members and supporting IEHP strategic goals.
  • Monitors performance of behavioral health providers and leads performance improvement efforts in the network to improve the quality of services delivered to IEHP members in collaboration with the Deputy Chief Medical Officer, Care Management, and Utilization Management.
  • Leads efforts to further integrate substance use treatment into the care delivery system, including implementing integrated care models that increase access to Medication Assisted Treatment (MAT) along with substance use counseling and other evidence-based addiction interventions.
  • Develops targeted education, training, and clinical guidance to contracted primary care physicians (PCPs) treating behavior health-related concerns not requiring referral to behavior health specialists.
  • Provides medical direction and guidance to the Behavioral Health Department in the arena of inpatient, outpatient pre-service authorizations and utilization management, including the coordination of care with external agencies, consultation on complex cases, and participation in Interdisciplinary Care Teams/case conferences.
  • Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality, cost, and outcomes.
  • Reviews cases and ensures appropriate adjudication of prior authorization. Directly reviews all medical necessity denials and modifications of prior authorization requests.
  • Ensures the creation, modification, and appropriate and timely use of UM criteria for both inpatient and outpatient authorizations.
  • Identifies and develops opportunities for innovation to increase effectiveness and quality.
  • Ensures that assigned patients have access to behavioral health services coordinated with primary and specialty care throughout IEHP’s geographic coverage area. Partners 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 IEHP behavioral health providers to ensure adherence to standards and quality of care. Coordinates professional interactions among practitioners and lends assistance toward correcting any deviation from standards. Develops relationships with directly contracted behavioral health providers.
  • Reviews State mandated benefits to ensure the IEHP Behavioral Health Program is in full compliance through its providers.

Position Requirements

  • Education: Doctorate of Medicine from an accredited institution required.
  • Certification: Certification by an American Specialty Board in Psychiatry.
  • Licensure: Possession of an active, unrestricted and unencumbered Physician’s and Surgeon’s Certificate issued by the State of California Medical Board required. (A physician certified in a state other than California may be employed prior to receipt of California certification provided that an application for a California physician and surgeon’s certificate is filed in the state of California prior to date of appointment.)
  • Experience: Five (5) years of post-residency or licensure experience in a recognized psychiatric specialty. At least three years of psychiatric administrative experience preferred. Preferred experience is in a variety of clinical settings including inpatient psychiatric, outpatient practice and community-based care settings. Utilization Management experience with an IPA, medical group or HMO highly desirable. Experience with Medi-Cal managed care is a plus.
  • Knowledge: 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; principles of effective supervision and organization; methods, techniques, practices, principles and literature in the broad field of medical sciences; and overview of the highly specialized techniques, procedures and equipment used in the medical or surgical specialties.
  • Skills: Microcomputer applications such as Microsoft Word, Excel and Access helpful.
  • Commitment to Team Culture: The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

IEHP Team Members are expected to ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures related to HIPAA compliance.

The position purpose, principal accountabilities, essential functions, minimum qualifications, and the requirements listed in this position description are representative only and are not exhaustive of the tasks that a Team Member may be required to perform. IEHP reserves the right to revise this job description at any time, and to require Team Members to perform other tasks as circumstances or conditions of its business considerations or work environment change.

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