Behavioral Health Medical Director in IL
Medical Dir, Health Plan Behavioral Health
Molina's Behavioral Health function provides leadership and guidance for utilization management and case management programs for mental health and chemical dependency services and assists with implementing integrated Behavioral Health care management programs.
Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
The Behavioral Health Medical Director performs the following functions with a focus on Behavioral Health within the Health Plan:
• Provides clinical input and guidance for all Care Management programs.
• Facilitates conformance to Medicare, Medicaid, Marketplace, NCQA and other regulatory requirements.
• Reviews quality referred issues, focused reviews and recommends corrective actions.
• Conducts retrospective reviews of claims and appeals, and resolves grievances related to medical quality of care.
• Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review, and manages the denial process.
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.
• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.
• Develops and implements medical policies.
• Provides implementation support for Quality Improvement activities.
• Stabilizes, improves and educates the Primary Care Physician and Specialty networks.
• Works with Contracting Department in contract negotiation.
• Monitors practitioner practice patterns and recommends corrective actions if needed.
• Fosters Clinical Practice Guideline implementation and evidence-based medical practice.
• Utilizes IT and data analysts to produce tools used to report, monitor and improve Utilization Management.
• Participates in regulatory, professional and community activities to provide input and become knowledgeable regarding regulatory, professional and community standards and issues.
Job QualificationsRequired Education
Doctorate Degree in Medicine (MD or DO) with Board Certification in Psychiatry
• 5+ years clinical practice.
• Current clinical knowledge.
• Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.
• Knowledge of applicable state, federal and third party regulations
Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.
• 2 years previous experience as a Medical Director.
• 2+ years HMO/Managed Care experience.
• 3 years experience in Utilization/Quality Program Management.
• Peer Review, medical policy/procedure development, provider contracting experience.
• Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.
This location houses the healthplan for the state of Illinois (we also have branches in downtown Chicago and Springfield), part of Molina Healthcare, Inc., a Fortune 200 multi-state health care organization that arranges for the delivery of health care services and offers health information management solutions to nearly five million individuals and families who receive their care through Medicaid, Medicare and other government-funded programs in fifteen states.