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

This position provides clinical leadership and support for the development and implementation of the Children’s Behavioral Health (BH) Carve-In program for Excellus BCBS, Univera Healthcare, and other subsidiaries of the Lifetime Healthcare Companies.

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

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About the Job:

• 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.
• 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.
• 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.

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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.