The Medical Director, Behavioral Health will support the Vice President of Behavioral Health and the Office of Clinical Affairs (OCA) in all areas of behavioral health (BH) disease / care management, quality management, and utilization management. S/he will also represent BMCHP in maintaining relationships with, and serve as a consultant on clinical policy related issues for, governmental organizations, regulatory groups, healthcare providers, and other external stakeholders.
Represents BMCHP behavioral health clinical leadership within the BMCHP medical structure providing guidance and behavioral health-focused information for clinical reviews and decisions.
Performs medical necessity utilization review, including peer clinical review, as needed.
Works with prior-authorization staff members on prior-authorization, concurrent, and retrospective review issues.
Collaborates with care management on member issues as needed.
Along with Vice President of BH and Quality and OCA leadership, develops and implements policies and procedures for management of mental health and substance use disorders in compliance with Massachusetts and New Hampshire regulatory standards.
Ensures that the application of clinical guidelines and policies is consistent with available research and regulatory guidance.
Participates on relevant quality and operational committees.
Provides training to BH staff on relevant behavioral health topics.
Works with clinical design and front line teams to develop processes and pathways that improve population health outcomes with an emphasis on complex/high risk members, common geriatric conditions and comorbid chronic disease.
Serves as behavioral health consultant for complex cases for BH and medical care teams
Participates in quality improvement initiatives regarding behavioral supports and the appropriate use of psychotropic medications in different populations
Consults with primary care and specialty care on shared care models
In collaboration with the Vice President of Behavioral Health develops and executes new strategic behavioral health clinical initiatives designed to support corporate goals.
Provides medical oversight of behavioral health management initiatives.
Collaborates with hospital physicians, medical directors, primary care physicians and nurse care managers in the coordination of behavioral health member care.
Reviews data from multiple sources to identify and respond to behavioral health trends and /or emerging issues.
Provides clinical consultation in the development, planning and management of complex cases.
Provides consultation on appeals cases.
Serves as subject matter expert on Pharmacy/ Behavioral Health interfaces
Doctorate Degree in Medicine (MD)
A minimum of five years direct clinical behavioral health experience is required.
A minimum of 3 years’ experience in medical management in a managed care setting.
Knowledge of accrediting organizations such as NCQA.
Knowledge of InterQual protocols, HEDIS, and other quality measures.
Knowledge of federal Medicaid and MassHealth regulations, guidelines, and standards
Experience with prior-authorization, utilization review, and appeals.
Experience in a health plan environment.
Certification or Conditions of Employment:
Board certification in psychiatry is required.
Board certification in Addiction Medicine is preferred.
Current unrestricted licensure as an M.D. in the Commonwealth of Massachusetts or, the ability to obtain unrestricted licensure within a reasonable period of time, is required.
Internal Number: 2013700
About BMC HealthNet Plan
BMC HealthNet Plan is a non-profit managed care organizations committed to providing the highest quality healthcare coverage to underserved populations. In Massachusetts, BMC HealthNet Plan is the business name for Boston Medical Center Health Plan, Inc.; outside Massachusetts, Well Sense Health Plan is the business name.