Behavioral Health Medical Director - UM Optimization
Core
Provide medical leadership for Utilization Management (UM) and cost containment, focusing on strategic planning, process optimization, and data analysis to improve quality and cost-effectiveness of care.
Role type
Senior Behavioral Health Medical Director (Utilization Management)
Builds
Strategic UM processes, quality improvement initiatives, and provider network alignment for managed care members.
Domain
Healthcare / Managed Care / Behavioral Health
Required skills
Strategic planning, data analysis, medical review, quality improvement, regulatory compliance, provider network development, clinical policy implementation, complex case management, stakeholder collaboration.
Preferred skills
Payer/Managed Care experience, Health Administration knowledge, experience with culturally diverse populations, active medical practice.
Technologies
None explicitly stated
Responsibilities
Provide medical leadership for utilization management and cost containment activities; perform medical reviews for utilization, quality assurance, and complex/experimental services; support performance improvement initiatives for capitated providers; assist in planning goals and policies to improve care quality and cost-effectiveness; provide expertise in operating quality improvement and UM programs; assist in functioning of physician committees; conduct rounds to assess and coordinate care for high-risk patients; collaborate with clinical teams and consultants on medical necessity appeals; participate in provider network development; develop and implement physician education programs; identify and evaluate utilization trends and adverse trends; review complex claims for medical necessity and payment; develop alliances with the provider community; represent the business unit on medical philosophy and policies.
Seniority
Senior, hands-on IC with strategic oversight