Medical Director, Children's Services (SafetyNet & Behavioral Health) (Finance)

Job Description:

The position provides clinical leadership and support for the development and implementation of the Children's Behavioral Health (BH) Carve-In program.

The Medical Director for BH Children's Services has overall accountability for BH services for all Medicaid Managed Care enrollees under age 21 years.

Essential Responsibilities/Accountabilities:

• Leads, develops, and implements the Children's Behavioral Health Carve-In program following NYS directives and guidelines.
• Completes medical necessity reviews and peer-to-peer calls in timely manner and provides support for the Case Management (CM) and Registered Nurse (RN) reviewers and manages the denial process.
• Leads interdisciplinary complex care management rounds.
• Provision of clinical oversight and leadership to Utilization Management/Case Management (UM/CM) staff working with the children's population.
• Develops, implements, and interprets clinical-medical policies and procedures (P&Ps) that are specific to the benefits and services of this transition or can be expected to impact the overall health, recovery and wellbeing of children.
• Ensures strong collaboration and coordination between BH and PH care across the UM/ CM staff.
• Participates in clinical peer review recruitment and supervision.
• Collaborates with Provider Relations staff to ensure an adequate provider network via required provider credentialing guidelines.
• Participates in BH provider quality profile design and data interpretation.
• Develops and implements the BH sections of the Quality Management/Utilization Management (QM/UM) Plan, including having the BH Medical Director for Children's Services and participate on the BH committees for QM/UM.
• Oversight on the Administration of BH QM/UM and performance improvement activities, including grievances and appeals.
• Attendance at regular (at least quarterly) Plan leadership and medical director meetings.
• Ensures strong collaboration and coordination between other child-serving systems, including the education system and foster care system.
• Develops, conducts concurrent and retrospective reviews of claims and appeals and resolves grievances related to medical quality of care, as needed.
• Ensures that the medical care provided to Children's Behavioral Health Carve-In program members meets the standards for acceptable medical care
• Fosters Clinical Practice Guideline implementation and evidence-based medical practice.
• Develops and implements performance and quality improvement initiatives that improve clinical outcomes and operational effectiveness.
• Interprets existing policies and develops new policies, as needed.
• Participates, as needed, in regulatory, professional and community activities to provide input and become knowledgeable regarding regulatory, professional and community standards and issue.
• Ensures that other Behavioral Health medical directors reviewing pediatric cases review those cases in accordance with Company policies.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Regular reliable attendance is expected and required.
• Performs other functions as assigned by management.

Note:

• The position is considered an exempt employee status with an expectation to work those hours which are required to accomplish the work deliverables including occasional evenings during high volume periods and staff shortages (e.g. cross coverage vacations).
• Work from home is an option with an expectation of full compliance with the corporate 'Work from Home' policy

Minimum Qualifications:

• Must hold a NYS medical license as a physician board certified in child and adolescent psychiatry without restrictions and free of sanctions from Medicaid or Medicare required.
• Minimum of five (5) years of experience working with children in BH managed care settings or BH clinical settings (at least two (2) years must be in a clinical setting).
• A minimum of ten (10) years medical experience and strong working knowledge of QM/UM.
• Ability to identify, analyze and resolve complex medical issues.
• Skills in evidence based medicine.
• Strong interpersonal skills essential for communication to staff at all levels of the organization.
• Basic skill sets in electronic communication systems such as e-mail and Word.

The Physician is not the subject of any pending professional disciplinary action impairing his/her ability to practice medicine.

Physical Requirements:

• Ability to travel across the health plan service regions as needed.

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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Min: $202,000 - Max: $303,000

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.