JOB SUMMARYThis job plays a crucial role in the corporation's success, and under direction by the chief medical officer and in collaboration with the senior director for behavioral health, works closely with all divisions and departments within the corporate structure to provide clinical consultation and support with regard to the behavioral health and addiction services program strategy and development, compliance with accepted medical standards, and practitioner/provider education. The incumbent is an integral part of the behavioral health utilization management team and assists utilization management staff by direct supervision or as otherwise appropriate to ensure delivery of quality and cost-effective care, member/provider satisfaction, and quality outcomes.
ESSENTIAL RESPONSIBILITIES- Provide utilization management reviews and clinical support for Medicaid, Medicare (DSNP) membership and Behavioral Health Pharmacy requests; communication of the decisions to the member and provider.
- Provide decisions for member and provider appeals and grievances, including ALJ and SFH
- Provide backup coverage for other BH medical directors in the Government segment as needed for PTO
- Provide clinical input into healthcare management services' activities relating to behavioral health and addiction medicine, including for example, care and case management, clinical program development, and network management. Provide clinical input to the Quality team to address HEDIS and NCQA metrics.
- Working with the network management and provider relations teams, act as a liaison for Highmark Wholecare and Highmark Health Options WV with practitioners/providers through ongoing communications and monitoring of services utilized.
- Contribute to development of the strategic direction for behavioral health for HWC and HHO WV as a member of the delivery system transformation team, help direct deployment and management of the virtually integrated partnership model.
- Serve as a resource for information and consultation on the issues related to utilization management, clinical services and medical affairs, including such issues as case management, disease state management programs, health risk assessments or other topics of general interest.
- Analyze utilization data and various forms of health care data available within and external to the corporation to evaluate effectiveness of clinical initiatives and care and case management processes. Identify factors for below quality standards and intervene as the spokesperson with local practitioners/providers to resolve care and case management issues and participate in the development of long-term strategies to create cost-effective medical care. Investigate and implement opportunities for cost savings initiatives to meet segment financial goals.
- Monitor clinical resource allocation, utilization and referral patterns, patient satisfaction, and clinical outcomes across the practitioner and provider network and at times make denials of services based on the absence of medical necessity.
- Provide findings to senior leadership and lead development of corrective action plans as indicated.
- Work with the credential staff to review provider applicants and to make decisions regarding approval, denial, and/or terminations according to Highmark Wholecare's and HHO WV policies and NCQA standards. Develop a working knowledge of the credentialing process and criteria and participate in its design.
- Regionally supervise and/or collaborate the activities/directives of the QI operations staff and committees. Attend corporate QI committee meetings, and report on regional actions related to committee function.
- Serve as a liaison to the state regulators (PA DHS, PA OLTL, & WV BMS)
- Other duties as assigned or requested.
EDUCATIONRequiredPreferred- Master's Degree in Business Administration/Management or Public Health
EXPERIENCERequired- 5 years as a Behavioral Health Physician OR Addiction Medicine Physician
- 3 years in a medical staff leadership or healthcare management role in Managed Care
- 3 years with Formal Quality and/or Utilization Management programs
Preferred- 7 years as a Behavioral Health Physician OR Addiction Medicine Physician
LICENSES or CERTIFICATIONSRequired- Unrestricted PA and WV Medical License with ability to obtain DE Medical License and other state licenses as needed to support business growth
- Board Certification in Behavioral Health
Preferred- Professional UR/QI certification
SKILLS- Proven ability to manage a project in order to accomplish established goals within a reasonable time period and through the use of developed organization and leadership skills
- Excellent communication and public speaking skills, well-developed interpersonal skills, and ability to interact effectively with members, practitioners/providers, colleagues, and local State and Federal agencies
- Familiarity with applicable State and Federal regulations and NCQA requirements for accreditation
Language (Other than English): Travel Requirement: PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition TypePhysical work site requiredDisclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:$227,600.00
Pay Range Maximum:$385,000.00
Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
