Adult Behavioral Health Medical Director

PURPOSE OF THE POSITION: The Behavioral Health Medical Director oversees the practices and corresponding documentation of all mental health and chemical dependence psychiatric services provided to children, adolescents and adults in accordance with governmental regulations. Reporting to the Chief Medical Officer, they help manage health plan behavioral health quality and costs while assuring appropriate health care delivery.

ESSENTIAL FUNCTIONS:

1. Provides professional expertise and services that support the Care Delivery Division, including, but not limited to, the following.

a) Utilization management:

• implements clinical guidelines and supports UM staff use of guidelines, protocols and criteria in conducting utilization review and case management activities;
• assures that corporate utilization policies comply with State and industry standards;
• works with the UM Director to analyze trends in service utilization, and develop and implement innovative care, case and disease management programs based on findings;
• performs daily prior authorization, concurrent and retrospective case reviews; and
• assists in oversight of delegated UM arrangements.

b) Credentialing:

• conducts the peer review component of corporate credentialing activities, assuring that credentialing decisions are supported by available utilization and quality of care information;
• assures that credentialing policies, standards and procedures are consistent with State and industry requirement and standards;
• confers with participating providers regarding clinical and quality data used in credentialing decisions.

1. Provider network:
   • works with other departments to assess network adequacy, and develop appropriate strategies to expand and strengthen provider network capabilities;
   • interacts and communicates directly with providers regarding network participation, access, availability, quality improvement and related clinical and service delivery issues; and
   • collaborates on strategies to assure that Affinity is the “health plan of choice” for providers.
2. Quality management and related initiatives:
   • conducts inter-departmental rounds to promote effective, efficient, high quality care management, and contribute to staff education and development;
   • staffs the Credentialing, Pharmacy and Therapeutics, and Medical Peer Review sub-committees, including development and direction of specialty peer review panels;
   • analyzes clinical and quality data to identify areas for performance improvement;

• works with inter-departmental staff, network clinicians, state and local health departments and industry colleagues to plan, implement and evaluate new programs, community outreach strategies, and clinical quality improvement activities; and
• participates in developing quality of care studies, and works with network clinicians to pursue subsequent quality improvement efforts.

2. Provides professional advice, guidance and support to other operational, analytical and strategic activities of the company, including, but not limited to, marketing, member services, claims, and public affairs.

3. Represents Affinity on appropriate local, State, and national trade groups, governmental and industry workgroups and committees and similar external venues; seeks opportunities to report on Affinity’s projects and programs.

4. Develops and maintains positive, constructive, mutually beneficial relationships that promote Affinity’s goal of being the “health plan of choice” for members, potential members, and providers.

QUALIFICATIONS:

1. License to practice medicine in New York State.
2. Appropriate training and expertise in general psychiatry and addiction disorders. Board certification is preferred.
3. Minimum of five (5) years of experience working with adults in behavioral health clinical or managed care settings. At least 2 of those years must be in clinical settings.