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Rancho Cucamonga

    Director, Medical Director - Rancho Cucamonga, CA, United States - Inland Empire Health Plan

    Inland Empire Health Plan
    Inland Empire Health Plan Rancho Cucamonga, CA, United States

    3 weeks ago

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    Description

    The Medical Director of Behavioral Health is responsible for clinical oversight, clinical leadership, and partnership in the management of the IEHP behavioral health activities in all lines of business.

    Areas of oversight for this position include, but are not limited to, case management, quality management, utilization management (UM), and grievance and appeals and committee participation.

    The Medical Director of Behavioral Health oversees the inpatient/concurrent review process, care integration efforts, and all levels of behavioral health care provided to IEHP Members.

    The Medical Director coordinates care with the County Mental Health Plans that are responsible for the care of the population with a Serious Mental Illness (SMI), the County Alcohol and Drug Program, as well as all IEHP community and provider partners.

    Provides overall clinical leadership and develops and implements clinical policies for the IEHP Behavioral Health Program.

    This includes delivery of mental health services, substance use services, medication management, and coordination of behavioral health services and primary care.

    Provides direction of current clinical practices for behavioral health services.

    Ensures that qualified medical/clinical personnel render clinical decisions regarding behavioral health, unhindered by fiscal or administrative management, and consistent with regulatory requirements and UM guidelines.

    Leads Behavioral Health quality improvement efforts while helping to manage health plan medical costs, assuring an appropriate and efficient health care delivery system for IEHP Members, and supporting IEHP strategic goals.

    Monitors performance of behavioral health providers and leads performance improvement efforts in the network to improve the quality of services delivered to IEHP members in collaboration with IEHP leadership.

    Develops targeted education, training, and clinical guidance to contracted primary care physicians (PCPs) treating behavior health-related concerns not requiring referral to behavior health specialists.

    Provides medical direction and guidance to the Behavioral Health Department in the arena of inpatient, outpatient pre-service authorizations and utilization management, including the coordination of care with external agencies, consultation on complex cases, and participation in Interdisciplinary Care Teams/case conferences
    Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality, cost, and outcomes.
    Directly reviews all medical necessity denials and modifications of a prior authorization requests.
    Identifies and develops opportunities for innovation to increase effectiveness and quality.

    Ensures that assigned patients have access to behavioral health services coordinated with primary and specialty care throughout IEHP's geographic coverage area.

    Partners with the Contracting Department to ensure a full and appropriate primary and specialty behavioral health care provider network for Members.

    Consults on written protocol for IEHP behavioral health providers to ensure adherence to standards and quality of care. Develops relationships with directly contracted behavioral health providers.
    Reviews State mandated benefits to ensure the IEHP Behavioral Health Program is in full compliance through its providers.
    Partners with Behavioral Health leadership in curriculum development designed to promote a comprehensive, effective, and equitable behavioral health program.
    Any other duties as required ensuring Health Plan operations are successful.

    Commitment to Quality:

    The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

    CalPERS retirement.
    Medical Insurance with Dental and Vision.
    Life, short-term, and long-term disability options
    Flexible Spending Account – Health Care/Childcare
    CalPERS retirement
    Doctor of Medicine from an accredited institution required.

    Possession of an active, unrestricted, and unencumbered Physician's and Surgeon's Certificate issued by the State of California Medical Board required.

    (A physician certified in a state other than California may be employed prior to receipt of California certification provided that an application for a California physician and surgeon's certificate is filed in the state of California prior to date of appointment.)

    Administrative practices and procedures including but not limited to quality assessment and improvement, utilization review, peer review, Credentialing, and risk management; rules, regulations, policies, and standards related to managed care; principles of effective supervision and organization; methods, techniques, practices, principles, and literature in the broad field of medical sciences; and overview of the highly specialized techniques, procedures, and equipment used in the medical or surgical specialties.

    Understanding of and sensitivity to multi-cultural community.
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