Current Board certification in Psychiatry and/or Child and Adolescent Psychiatry
Active Pennsylvania Medical License
Minimum of 5 years of clinical psychiatry experience, particularly in inpatient care and substance abuse treatment
Strong understanding of managed care principles and medical assistance regulations
Responsibilities
Review cases for medical necessity across various sites and care levels
Conduct peer reviews for disputed care levels
Perform medical necessity reviews
Make decisions on care denials based on medical necessity
Engage with providers on clinical and administrative issues
Guide Clinical Care Managers on complex cases
Participate in clinical and administrative meetings
Benefits
Opportunity to influence high-quality mental health care
Collaborative work environment with clinical providers
Role in strategic oversight of behavioral health services
Professional development and leadership opportunities
Commitment to diversity and member-centric care
Full Job Description
Position Overview:
The Physician Advisor provides strategic oversight of medical necessity determinations for behavioral health services, ensuring alignment with clinical standards and organizational objectives. This role is accountable for conducting medical necessity and peer reviews, directing the activities of the crisis team, and fostering collaboration with clinical providers to promote high-quality, effective mental health care for CBH Members.
Essential Functions:
Review cases from multiple sites and levels of care for medical necessity.
Peer review cases for disputed levels of care.
Perform medical reviews
Make denial decisions based on medical necessity
Participate in clinical and administrative meetings.
Interact with providers on clinical and administrative matters.
Serve as clinical leadership resource and consultant to Clinical Care Managers, offering guidance on complex cases and best practices.
Position Requirements:
Education:
MD/DO from Accredited Medical School
License/Certification:
Current Board certification in Psychiatry and/or Child and Adolescent Psychiatry by the American Board of Psychiatry and Neurology; Current and Active State of Pennsylvania Medical License
Relevant Work Experience:
Minimum of 5 years of clinical psychiatry experience including significant and specific experience with inpatient care and substance abuse treatment
Skills:
Ability to provide clinical oversight on a wide array of operational activities.
Strategic planning
Financial planning
Excellent written and verbal communication skills
Familiarity with medical assistance regulations and managed care principles and practices
Knowledge of Managed Care Organization operations and principles.
Demonstrated leadership ability.
Core Expectations:
Community Behavioral Health (CBH) will hold each employee accountable for the following expectations, which align with our mission, vision, and corporate code of conduct.
Perform key responsibilities as detailed in this job description in a dependable, responsible, and positive manner, consistent with all state and federal guidelines.
Serve as a role model by exemplifying professional behavior, language, skills, and attire to promptly and accurately serve the needs of stakeholders, members, and their families.
Assure adherence to CBH policies and procedures so that all work is of the highest quality and delivered in the most culturally competent and cost-effective manner.
Promote and manage diversity and acceptance within CBH and with all members and stakeholders by honoring and respecting their individuality, dignity and rights.
Offer suggestions and develop solutions to help promote effective and efficient work processes and innovative programs.
Actively participate in required meetings and complete all mandatory trainings.
Maintain high levels of advocacy and member confidentiality to ensure the success of CBH and our mission.
Assist in assuring both internal and external program integrity by being alert to and reporting suspected instances of provider and employee fraud, waste or abuse.
Core Competencies:
Teamwork and Collaboration: Build and sustain relationships with co-workers and stakeholders and support efforts and deliverables. Encourage unity and help remove barriers to productivity and success.
Respect: Treat each other and our members and stakeholders with respect and sensitivity, recognizing the importance of diversity.
Member Centric: Focus on the needs of our members by providing value-added services, promoting strong relationships and going beyond basic expectations to achieve the best possible outcomes.
Honesty and Integrity: Be open and honest in all we do. Always maintain the highest level of integrity.
Commitment to Service Excellence: Challenge ourselves to be forward-thinking and committed to providing total member and stakeholder satisfaction, first-in-class service and high quality, innovative programs.
Compassion and Empathy: Demonstrate a deep appreciation for another's situation and point of view. Pay attention to emotional cues, listen effectively and show an exceptional care about each person's perspectives and circumstances.
Problem Solving: Build and implement logical solutions to resolving challenges/issues by using individual knowledge and experience while taking resources, constraints and CBH values into consideration.
Initiative and Self-Directed: Proactively manage time and resources in a way that ensures that all work is done in the most efficient manner while identifying and implementing initiatives without interventions from co-workers, supervisors or stakeholders.
Flexibility and Adaptability: Adjust approaches and behaviors in order to meet the constantly changing environment head-on and accomplish CBH and individual goals. Strive to adapt to, accept and embrace change within areas of responsibility.
Communication: Effectively and appropriately share thoughts, ideas and information - both written and oral. Respectfully listen to co-workers and stakeholders to gain a full understanding of issues/situations.
Leadership Competencies:
Strategic Thinking: Understand and integrate the long-term vision of CBH and focus current activities on what is critical to achieve future success including formulating objectives/priorities and developing and implementing breakthrough ideas.
Leadership: Effectively manage and guide efforts to address challenges and drive continuous improvement for CBH's programs, services and processes. Develop and implement effective strategies and appropriate interpersonal styles to influence and guide others.
Employee Development: Recognize and promote the necessity to hire, assess, develop and retain high quality talent. Acknowledge strengths and weaknesses in team members through an ongoing performance management process that provides timely feedback in order to help them develop and enhance performance.
CBH Requirements and Accommodations:
Philadelphia Residency Requirement:
The successful candidate must be a current Philadelphia resident or become a resident within six months of hire.
U.S. Authorization Requirement:
CBH does not provide sponsorship for applicants requiring future work authorization. All candidates must be legally authorized to work in the United States without requiring sponsorship now or in the future.
About Community Behavioral Health, Inc
Community Behavioral Health, Inc. (CBH) is a non-profit organization that provides mental health and substance abuse services to Medicaid recipients in Philadelphia, Pennsylvania. CBH was established in 1997 and is responsible for managing the behavioral health benefits for over 700,000 Medicaid recipients in Philadelphia. The organization works with a network of over 200 providers to ensure that individuals receive the care they need. CBH is committed to improving the quality of life for individuals with mental health and substance abuse disorders and their families.
