Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, andanticipatedcontributions to meet the needs of the business, along with internal pay equity and externalmarket-drivenrates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may bemodifiedin the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

This position will provide physician leadership and support to Capital9s behavioral health (BH) program, As a clinical leader in mental health and substance use disorders, this position will collaborate cross-departmentally (internally) and with key external stakeholders, including Capital9s network providers, to provide BH expertise and drive Triple Aim outcomes in support of Whole Person Care. The position will also provide clinical leadership to the development, evolution, and implementation of Capital9s BH strategy, including any vendor-supported programs and services. This position will help ensure Capital9s BH clinical programs are robust and market leading. When gaps are identified, this position will help develop and implement new programs and services. In partnership with internal stakeholders and our network providers, this position will champion provider practice transformation in support of strategies to increase access and availability of care, including physical and BH integration and other alternative payment models. Analysis of data will be critical to identify improvement opportunities and modifications to current strategy.

• Provides physician insight and collaborates in the development and evolution of Capital9s BH program and strategy.
• Participates in and advises Capital committees (e.g., Quality Improvement Committees, Utilization Management Committees, Member Safety Committee) on BH topics and strategy development.
• Provides oversight, guidance, consultation and expertise to Capital9s BH clinical operations, including utilization management, care management, complex case reviews and clinical rounds.
• May provide limited cross-coverage support for Care Management and Utilization Management activities, including consultation on complex cases, clinical rounds, or care coordination initiatives, as business needs require.
• Reviews data to identify trends relating to BH clinical operations and provides feedback on medical necessity criteria and/or medical policies underlying BH utilization management decisions and subsequent appeals.
• Collaborates cross-departmentally (internally) and with key external stakeholders, including Capital9s network providers, to drive Triple Aim outcomes. Provides BH expertise to inform clinical programs and services that drive quality and HEDIS, STAR, and CAHPS improvement.
• Works directly with Capital network providers and internally within Capital to champion provider practice transformation in support of Capital9s value-based delivery models. Establishes relationships and regular touchpoints with key BH network providers to collaborate on opportunities to improve health outcomes for Capital9s members.
• Provides clinical leadership to the development and evolution of strategies to improve access and availability of BH care and services to Capital members, including physical and BH integration models (collaborative care models) and integrated care management programs among others.
• Provides clinical leadership to the development and executes on the strategic direction for Capital9s BH strategy, including any vendor-supported programs and services. Helps to promote Capital9s clinical vision and programs in the local medical community and within Capital9s 21-county service area.
• Reviews and analyzes data to drive that transformation in improving member health, experience of care, and medical costs.
• Supports organizational accreditation efforts and regulatory review processes, including participation in key committees and quality improvement activities Performs activities in compliance with all applicable regulatory entities including NCQA, CMS, PID, and DOH, among others.
• Performs other related duties and assignments as requested and directed.

Skills:

• PC literacy and ability to perform electronic research and respond to electronic requests
• Team oriented attitude with the ability to work and interact with all levels both within and outside of CBC
• Ability to effectively multi-task under pressure, meet deadlines, and deliver high-quality work
• Ability to move from broad strategic perspective to tactical implementation and translate thoughts into actionable plans to drive performance
• Ability to convey complex or technical information in a manner that others can understand.
• Demonstrated organizational and time management skills.
• Self-motivated and works independently; highly accountable.
• Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions, and devise appropriate courses of action
• Demonstrated ability to drive results to completion while managing multiple projects and priorities competing for resources.
• Ability to complement leadership and other team members in their responsibilities and roles

Knowledge:

• Knowledge of current and emerging BH trends, including physical and behavioral health integration models,
• population health, and alternative payment models
• Knowledge of and prior involvement with complex and unique issues within the health care industry
• Knowledge of health plan regulatory requirements, including CMS, NCQA, and the DOH

Experience:

• A minimum of five years of clinical experience, post residency, including both inpatient and outpatient mental health and/or substance use disorder.
• A minimum of 8 years of experience in health care with an emphasis on analysis and process optimization.
• Managed Care Organization and/or health insurance plan experience preferred.

Education and Certifications:

• MD or DO Degree, as well as appropriate Board Certification.
• Current unrestricted license in Pennsylvania as an MD or DO.
• Currently covered by, or eligible to be covered by, medical liability insurance.
• Current valid Pennsylvania drivers9 license.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must occasionally lift and/or move up to 5 pounds.