Medical Director, Behavioral Health

Join Our Team as a Medical Review Director- Behavioral Health!

Are you a dedicated and experienced medical professional with a passion for quality improvement and healthcare administration? We are seeking a self-motivated and detail oriented Medical Review Director to lead our team in ensuring the highest standards of medical necessity determinations and clinical metrics analysis.

You may be a great match for this role if you are a versatile board-certified psychiatrist with management experience in the areas of behavioral health and addiction medicine. We’re looking for candidates who are versed in leading multidisciplinary teams in developing and standardizing behavioral health programs and quality measures and are skilled in providing multidisciplinary staff supervision with a minimum of five years of clinical experience in a variety of managed care treatment settings. Work experience within the insurance industry is preferred but not required.

In addition to the job responsibilities below, this Medical Director will be responsible for:

• Medical necessity reviews and appeals
• Conducting peer to peer reviews
• Medical supervision of utilization management and case management staff
• Reporting quality of care concerns
• Participation in medical policy development
• Participation in credentialing activities for incoming providers and providing leadership in improving treatment outcomes

Job Responsibilities

• Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines.
• Analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiatives.
• Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews.
• Lead and serve on various committees in order to accomplish medical utilization, cost and quality objectives of BCBST.
• Willingness to travel within the State of Tennessee and nationally.

Job Qualifications

Education

• Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Tennessee required. *However, this requirement can be waived for jobs where the totality of the incumbents duties and responsibilities are restricted to the performance of administrative duties only.
• Completion of a MD Residency training program in Psychiatry.

Experience

• 5 years - Clinical experience required
• 2 years - Inpatient or hospital-based treatment experience required
• 5 years - Healthcare administration, including UM experience required
• 3 years - Experience in dual Medicare/Medicare SNP programs required

Skills\Certifications

• Board Certification in psychiatry (a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists).
• Ability to conceive and deliver innovative solutions
• Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
• Outstanding negotiation, presentation, and facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)
• Excellent oral and written communication skills
• Ability to lead and motivate cross-functional, interdisciplinary teams to achieve tactical and strategic goals.
• Substantial knowledge of mental health and chemical dependency services and practices, including treatment techniques, discharge planning and transitions of care.

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Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Tobacco-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test.  An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine  and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.

Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.