Medical Director – Behavioral Health

Position Summary:

The Behavioral Health Medical Director will provide clinical expertise to Community Care Plan (CCP), working closely with all the clinical departments.   The Behavioral Health Medical Director will provide insight and support to Quality, Care Coordination, Pharmacy and Community Health. They will help develop internal policies and workflows for CCP. and will also oversee the utilization management processes for the behavioral health including the Severe Mental Illness (SMI) population within Florida Medicaid Managed Care. This role requires a dynamic leader with extensive experience in behavioral health, particularly in managing and optimizing care for individuals with SMI. The Medical Director will ensure that all utilization management activities align with state regulations, Medicaid policies, and best practice standards while improving care quality and outcomes for members.

Essential Duties and Responsibilities:

1. Clinical Oversight and Leadership:
   1. Clinical Expertise and support for various Managed Care departments:
      1. Assists in the growth and development of the Case Management Program providing clinical expertise to Care Coordination process. Participating in State mandated care management meetings.
      2. Ensure clinical practices and decisions adhere to evidence-based guidelines and standards of care.
      3. Reviews and monitors Grievance and Appeals cases serving as a resource for G&A Team
      4. Reviews and monitors Risk Management PQI’s and Adverse events serving as a resource for Risk Management.
      5. Participates in Root Cause Analysis of specific member events.
   2. Ensures that appropriate utilization decisions are implemented:
      1. Develops, implements, and monitors the Utilization Review Plan.
      2. Develops and monitors utilization and quality improvement reporting mechanisms.
      3. Develops practice guidelines for high volume diagnoses or specific instances for the populations we serve, in conjunction with the appropriate specialists.
      4. Educates external physicians and staff about utilization practices to promote high quality, cost-effective care.
      5. Develops written policies for the resolution of utilization problems.
      6. Plans and conducts interventions with outlier physicians.
      7. Recommends needed physician, facility and/or ancillary contracts to the Director of Provider Operations.
      8. Conducts in-patient conferences with Utilization Management Manager/Supervisors to monitor the patient care activities weekly.
      9. Acts as a resource for the Utilization Review Nurses.
      10. Reviews frequent or unusual referral reports.
      11. Reviews all referrals that have potential for denial of services.
      12. Ability to perform Peer to Peer conversations with external physicians and staff that are providing services for our members.
      13. Interfaces with Community Care Plan medical directors as needed on utilization issues.
      14. Provides report to Medical Operations and engages with practices for over and underutilization in specific populations.
      15. Attends all meetings, as needed.
2. Quality Improvement:
   1. Develop and implement quality improvement initiatives aimed at enhancing care delivery and outcomes for all members with a focus on SMI population.
   2. In partnership with Provider Operations, monitors the results of the Satisfaction Surveys and implements corrective action, when necessary.
   3. Collaborate with quality management teams to assess and address performance metrics and clinical outcomes.
3. Compliance and Regulatory Adherence:
   1. Ensure compliance with Florida Medicaid Managed Care regulations, state laws, and federal guidelines related to behavioral health and SMI.
   2. Conduct regular audits and reviews to ensure adherence to clinical standards and regulatory requirements.
   3. Prepare and submit required reports and documentation to regulatory bodies.
4. Stakeholder Collaboration:
   1. Work closely with interdisciplinary teams, including behavioral health providers, case managers, and other healthcare professionals, to coordinate and optimize care for Medicaid members with a focus on SMI population.
   2. Engage with external stakeholders, including community organizations and advocacy groups, to support integrated care initiatives and resource development.
5. Education and Training:
   1. Provide training and support to utilization management staff, clinical teams, and other stakeholders on best practices and emerging trends in behavioral health and SMI care.
   2. Stay abreast of advancements in behavioral health treatments and methodologies and integrate them into the utilization management framework.
6. Strategic Planning and Development:
   1. Contribute to the strategic planning and development of behavioral health programs and services tailored to the needs of the SMI population.
   2. Analyze utilization data and trends to inform strategic decisions and resource allocation.
7. Professional and Personal Conduct:
   1. Works at maintaining a good rapport and a cooperative working relationship with health plans, physicians, and office staff.
   2. Represents Community Care Plan in a positive and professional manner in the community.
   3. Always maintains patient and organizational confidentiality.