Job Description

Job Brief

Board-certified in general psychiatry and current license in South Carolina required.



Your career starts now. We\xe2\x80\x99re looking for the next generation of health care leaders. At AmeriHealth Caritas, we\xe2\x80\x99re passionate about helping people get care, stay well and build healthy communities. As one of the nation\'s leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we\xe2\x80\x99d like to hear from you. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.
The Behavioral Health Medical Director serves as a subject matter expertise in the operational areas of Behavioral Health utilization reviews and appeals, while collaborating on clinical quality improvement, case management and related policy and practice initiatives related to Behavioral Health in collaboration with the Corporate Behavioral Health Medical Director. The following responsibilities as it pertains to working with enrollees diagnosed with mental illness and substance abuse conditions and their providers:

• Identifies and ensures evidence-based practice guidelines are utilized throughout the provider network

• Oversees the quality of clinical care for network and non-network providers

• Engages the provider network in identifying quality of care concerns and works with Continuous Quality Improvement through the diffusion of practice standards, and through an internal quality assurance program that measures network provider performance against standards of high quality, especially the performance standards embodied in the HEDIS program.

• Utilizes a high-performing medical management system that adheres to the terms of contracts and all relevant regulatory requirements.

• Utilizes evidence-based standards in making coverage determinations

Accountabilities:

• Ensures the provision of quality and clinically sound behavioral health care services to all enrollees by associates and providers.

• Serves as medical advisor and manager for all behavioral health clinically related activities.

• Assures that organizations medical policies and procedures adhere to contractual obligations.

• Performs clinical case reviews in conjunction with the Medical Excellence Department responsible for HEDIS performance

• Maintains familiarity with federal, state, and local regulations that may pertain to the medical and clinical operations.

• Works with clinical leadership in the development and implementation of medical policy as it relates to behavioral health management.

• Maintains compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations.

• Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting contractual obligations.

• Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff.

• Assists in the trains staff on behavioral health-related issues and provide consultation to staff as appropriate.

• Assists IHC Managers in assessing members\xe2\x80\x99 need for case management services.

• Attends case management meetings and monthly rounds as scheduled.

• Collaborates with the integrated case management team, during scheduled meetings and informally as needed.

• Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports execution of ACFC mission and values.

• Other duties as assigned.

Education/Experience:

• MD

• 3-5 years of experience in clinical practice.

• Must be licensed to practice within the state of South Carolina and be willing to obtain additional state licensures as required for business purposes.

• A board-certified in general psychiatry is a minimum requirement with ongoing maintenance of certification. Additional certification in child and adolescent psychiatry or addiction would be a plus

• Must be clear of any sanctions by the applicable state or Office of the Inspector General.

• Must not be prohibited from participating in any Federally or State funded healthcare programs.