Medical Director, Behavioral Health
Oregon, Utah, Idaho or Washington
The Medical Director Behavioral Health: Conducts case reviews requiring physician involvement and/or provides clinical expertise to others related to behavioral health case management, prior authorizations and appeals. Provides peer-to-peer consultations with providers. Partners with leaders and staff across the organization to ensure policies, programs and strategies related to behavioral health are integrated, cost effective, and appropriately support health outcomes for our members. Provides leadership, strategic direction and clinical oversight for behavioral health services across all lines of business within the health plan.
General Functions and Outcomes
- Develops and oversees Cambia's behavioral health medical policies, strategies, and programs to ensure they are high quality and market competitive.
- Provides leadership in developing, implementing and communicating short and long-range plans, goals and objectives for the cross-functional behavioral health team.
- Oversees the development of effective operational policies, procedures and standards for an effective, integrated behavioral health program. Monitors utilization and results and implements process or system changes as needed.
- Serves as a subject matter expert on behavioral health. May work with government affairs team to develop and advocate for related policies and regulations.
- Provides medical advice, oversight and leadership for staff to ensure members receive safe, effective and cost efficient services. Provides clinical input on case management reviews working closely with the Case Management clinical staff.
- Discusses review determinations with providers who request peer-to-peer conversations. Promotes provider understanding of utilization management and quality improvement policies, procedures and standards.
- Leads and/or participates on various teams to provide clinical input on medical policy reviews and development. Collaborates with others to implement actions to reduce medical cost trend (e.g. through medical policies, vendor programs, provider communication and coding).
- Stays abreast of industry, medical and technology trends. Identifies and communicates new opportunities in utilization management, provider contracting or other areas that would enhance outcomes and the reputation of the organization.
Normally to be proficient in the competencies listed above
- In-depth knowledge of best practices related to medical care for a wide variety of behavioral health conditions.
- Demonstrated competency working with hospitals, provider groups, or integrated delivery systems to effectively manage patient care to improve outcomes.
- Passion for population health, healthcare transformation and improving the experience of people with mental health issues.
- Strong communication and facilitation skills with internal staff and external stakeholders, including the ability to resolve issues and seek optimal outcomes.
- Proven ability to develop and maintain positive working relationships with community and provider partners.
- Knowledge of the health insurance industry, state and federal regulations, provider reimbursement methods and evolving accountable care and payment models.
- Experience conducting medical case reviews for utilization and/or case management.
- Detail-oriented with orientation to the application of data and metrics in managing health, quality and program effectiveness.
- Leadership experience with demonstrated ability to effectively build relationships, work with others and lead people and project teams.
The Medical Director would have a MD or DO degree, at least 3 years clinical experience, plus 2 years health plan medical utilization management and/or case management experience or equivalent combination of education and experience.Required Licenses, Certifications, Registration, Etc.
Licensed Physician with an MD or DO degree related to behavioral health. Active, unrestricted license to practice medicine in one of our four state footprint (Oregon, Utah, Idaho or Washington) or more states or territories of the United States. Board Certification required.
Qualification by training and experience to render clinical opinions about medical conditions, procedures, and treatments under review.Work Environment
- Work is primarily performed in office setting and/or remotely.
- May be required to work outside normal working hours.
- Must be located in a state or territory of the United States when conducting a peer clinical review.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check is required.
Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members more than 90 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com