Provide clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent responsive medical care.
Co- Lead development/ integration of Behavioral Health UM & case management at Health Plan.
Support Health Plan’s strategic plan to identify and exploit new business opportunities to achieve Better Health/ Wellness of the patients/ families served.
Experience with the SMI population (Seriously Mentally Ill) for this role is critically important.
MAJOR DUTIES AND RESPONSIBILITIES:
Leads the clinical staff in the coordination of members’ quality care according to benefit plans.
Provides support with clinical expertise/ business direction for medical management/UM programs
Tracks and trends under/over utilization of behavioral health services & identifies opportunities to improve outcomes.
Provides clinical guidance for effective quality medical program operation, management and reduction of any lapses in the quality of care.
Assists in development of annual QI plan for all programs assuring all indicators are met; participates in quality management to achieve NCQA and URAC accreditation. Analyzes data/identifies quality improvement opportunities.
Mentors and supports employees and ongoing training and development of staff.
SKILLS AND ABILITIES:
Experience working with the SMI (Seriously Mentally Ill) population
Foster a culture of caring for patients and employees.
Demonstrates competence in written, oral, and electronic communication skills,
Coordinates and directs programs, projects, resources, and staff across company,
Possesses strong analytic qualities to assess goals, products, programs, processes & make recommendations for changes,
Skilled in managed care UM, DM and QM
Experience using clinical documentation programs designed for utilization management programs,
Interact and mentor colleagues
EDUCATION AND/OR EXPERIENCE:
2-3 years of experience in an integrated health care delivery system, clinical practice and health industry. Managed care experience is a preferred.
MD or DO
Licenses and Certification: Medical/Board Certified, Psychiatry is required. An active unrestricted medical license in the state of Pennsylvania is required or the ability to obtain an active unrestricted license in Pennsylvania is required within 2 months of hire.
MD or DO
Board Certification Psychiatry
Active Medical License in State of Profession with Ability to Obtain PA License
2-3 Years in Clinical Practice and a Provider and Payor Settings
Health Plan UM, QI, Chronic Care Management, Claims and Appeals Review, Data Analysis, Physician Relations, Project Management , Success Preparing for URAC or NCQA Accreditation
Strong Interpersonal, communication and presentation skills