The position is responsible for providing the clinical leadership for behavioral health in the assigned market. The position will help provide direction and management of behavioral health staff located in assigned markets which may include Behvaioral Health Concurrent Review, case management, and provider relations staff.
In this role, the selected candidate will demonstrate support of services, service enhancement, quality improvement, equipment evaluation, supply utilization, department design, human resource management, financial performance, and maintenance of current standards of care.
In this position, you will participate in the attainment of quality management goals to meet or exceed quality standards as established by all external agencies. Participate in the identification and analysis of medical information from multiple
In this role, you will be responsible for chairing appropriate health services committees and providing leadership for pharmacy and health services utilization management projects for single-market health plans.
In this role, you will perform benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles.
In this role, the selected candidate will conduct coverage review based on individual member plan documents, and national and proprietary coverage review guidelines, render coverage determinations, and discuss with requesting providers as needed in peer-to-peer telephone calls.