Behavioral Health Medical Director
The Behavioral Health Medical Director will actively use their medical background, experience, available criteria and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. They will support peer to peer communication for disputed determinations. In addition, the BH Medical Director will utilize their medical background to review Quality of Care (QOC) concerns and make recommendations to the Quality Management Team as requested related to quality of care consistent with evidence-based guidelines. As needed, they will support and share expertise with the behavioral health medical management team, quality management team and will support assigned committees as well as attend required committee meetings. As needed, they may recommend and help right policies and procedures in support of improvement in utilization management.
- Engages in review of Quality of Care (QOC) reviews as requested.
- Supports and provides medical expertise for operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
- May use his/her expertise to identify utilization review studies and evaluates adverse trends in utilization and prior authorization.
- Identifies and leads clinical quality improvement projects to decrease variation and to improve the quality and cost of care.
- Serves as a lead physician advisor by supervising and performing medical case review, adopting guidelines and criteria in order to assure optimal efficiency in the management of patient care. Educates physicians, health professionals, managerial staff and the patient population about managing the continuum of care for optimal utilization of resources.
- Makes determinations of prior authorization requests for services and retro-review services for medical necessity. Works with utilization review nurses to complete utilization review activities and make coverage determinations for members admitted to inpatient facilities. Works collaboratively with case managers to develop effective care plans for members with complex conditions. Communicates with providers as needed to resolve disputes or disagreements related to coverage determinations. Oversees provider education, in-service training and orientation.
- Provides leadership, supervision, guidance and development for staff, articulating and demonstrating an expectation for continuous quality improvement, as well as continually supporting and exhibiting company values and service standards. Identifies and provides growth opportunities for staff. Participates in review of qualifications, credentials, performance, and professional competence and character of physician and provider stakeholders. May participate in medical staff professional review process and physician recruitment.
- Ensures and fosters a high level of collaboration within a highly matrixed team environment in order to coordinate activities, review work, exchange information, and resolve problems. Champions, models, and promotes service excellence philosophies and behaviors to enhance the overall patient experience.
- Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors every day.
The essential functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.
- Medical Doctorate or Doctor of Osteopathy Degree required with appropriate Board Certification or qualification of clinical practice experience.
- An unrestricted AZ medical license as well as Board Certification for the state of AZ
- Must possess strong clinical knowledge to support review for medically appropriate utilization of medical services and case management with a minimum of five (5) years of clinical practice.
- Must possess strong interpersonal skills to generate collaboration and enable independent decision making among internal and external clinical staff.
- Must possess a strong knowledge and understanding of managed care operations, reimbursement models, medical protocols and criteria including Medicare criteria, and peer review statutes as normally obtained through 5 years of medical practice experience.
- Must possess a current knowledge of clinical protocols, reimbursement challenges, and managed care principles.
- Must possess excellent oral, written and interpersonal communication skills to effectively interact with all levels within the organization, as well as outside parties.
- Experience with hospital organized medical staff, managed care organizations, and continuous quality improvement activities is preferred.
- Proven track record leading physician groups, including group facilitation, leadership development, teambuilding, performance management, and driving cultural change.
- Proven experience implementing a continuous improvement culture.
- Proven track record of partnering with medical staff to achieve desired organizational outcomes.
- Knowledge of modern national trends in hospital technology, quality and patient safety.
- Knowledge of health care reform, population health management, and ACO trends and developments.
- Skilled in effectively handling multiple conflicting assignments, demands, and priorities with great attention to detail.
- Establishing, pursuing, and monitoring appropriate process and outcome measures for key initiatives utilizing a systems perspective; evaluating the processes by which clinical care and patient services are delivered, identifying areas for of opportunity, setting standards for outcomes, developing appropriate systems to monitor outcomes, and overseeing the implementation of process improvements.
- Quickly assessing and assimilating industry trends in order to act quickly and appropriately to changing environmental factors; influencing others and translating strategies into actions; motivating physicians and building teams; influencing physician behaviors; partnering and problem solving with physicians and hospital and practice management leaders.
- Excellent human relations, organizational and communication skills are essential.
- Leadership style and characteristics necessary to effectively perform in this role include: strong work ethic; results-oriented; persuasive; motivational; able to make rational decisions in difficult situations; inspirational; honorable; confident; systems-thinker; innovative; life-long learner; courageous; high-energy; integrity; collaborator; ability to work with teams; good listening; nonvolatile; values multiple disciplines; and passionate about continuously improving and providing high quality care and service excellence to patients, families, employees and physicians.
- Administrative or managed care experience is highly desirable
- MBA or similar degree is preferred