Overview
We are seeking a Behavioral Health Associate Medical Director to provide part-time clinical leadership and subject matter expertise in support of the Group Health utilization review program. This contract role provides clinical oversight of behavioral health physician reviewers, supports quality management and reviewer development, and serves as a physician resource for operational teams and clients. The anticipated commitment is approximately five hours per month, with additional participation as mutually agreed based on business or client needs.
Key Responsibilities
- Provide clinical oversight and subject matter expertise for behavioral health utilization review activities.
- Audit initial cases completed by newly onboarded behavioral health physician reviewers and provide feedback, coaching, or retraining when needed.
- Perform ongoing and targeted audits of behavioral health panelists based on quality trends, client grievances, overturn patterns, escalations, or other identified performance concerns.
- Review potential quality misses or inappropriate determinations and provide timely clinical feedback and remediation to physician reviewers.
- Support QA and operational staff with live case escalations involving behavioral health determinations, rationale quality, evidence-based support, peer-to-peer requirements, or reviewer performance.
- Monitor remediation effectiveness and provide follow-up guidance when quality concerns persist.
- Assist with behavioral health reviewer training and maintenance of reviewer training expectations and documentation.
- Participate in quality management and quality improvement activities related to behavioral health review services.
- Respond to client escalations or grievances involving behavioral health physician determinations and assist with root-cause review and remediation plans.
- Participate in client-facing calls, audits, and touch-base meetings as the behavioral health physician subject matter expert, including discussion of clinical quality, reviewer performance, and corrective actions.
- Participate in prospective client discussions as needed to provide physician perspective regarding behavioral health capabilities, panel oversight, and quality monitoring.
- Collaborate with Group Health leadership, Medical Director leadership, QA, operations, and physician network teams to support consistent, high-quality behavioral health utilization review.
Requirements
- MD or DO with board certification in Psychiatry; Child and Adolescent Psychiatry experience or certification preferred.
- Active, unrestricted medical license.
- Prior utilization review experience, preferably within a health plan, independent review organization (IRO), managed care, or similar environment.
- Demonstrated experience with ASAM Criteria and behavioral health medical necessity and level-of-care review.
- Working knowledge of behavioral health utilization management criteria and guidelines, including LOCUS/CALOCUS, MCG, and InterQual.
- Strong clinical judgment and ability to evaluate the quality, consistency, and defensibility of physician determinations and rationales.
- Strong written and verbal communication skills, including the ability to provide effective physician feedback and participate in client-facing discussions.
- Ability to work independently and respond promptly to time-sensitive clinical or quality escalations.