Job Title: Regional Medical Director CCB Job ID: 66364310 Status: Full-Time Regular/Temporary: Flex Hours: Shift: Day Job Facility: Community Care Behavioral Health Department: PeerAdv-PerfMgmt-LC Location:
Purpose: The Regional Medical Director is responsible for assuring the quality and efficiency of the health care delivered to Community Care members. This includes significant responsibility for quality management and utilization management and for assuring the adequacy of the provider network for the clinical needs of Community Care members. The Medical Director also participates in regional leadership policy decisions and strategic planning. In addition, the Regional Medical Director is a resource to participating providers in the provision of quality medical care.
Assures psychiatric involvement in the development, approval, and review of all policies, procedures, and protocols governing clinical care.
Interfaces with the Counties and DPW as indicated.
Ensures the quality of clinical care provided to Community Care members
Supports provider satisfaction with the care management process.
Assures the quality of treatment and related services provided by Community Care professional staff, through participation (directly or by designee) in the ongoing quality management and audit processes.
Reviews of complaints and grievances in accordance with Community Care procedures, and to assure prompt response and action at all stages of the complaint and grievance process.
Meets or exceeds NCQA, URAC or other regulatory standards
Interfaces with the Physical Health MCO's through Medical Director to Medical Director meetings, and sits on appropriate committees of the PH MCOs.
Develops and maintains effective relationships with providers.
Reviews the medical aspects of cost and utilization reports generated by Medical Management Information System.
Participates in the appropriate committees of physical health HMO's where applicable, such as a pharmacy and therapeutics committee.
Advises the Regional Director on the development and review of programs, positions, and budgets having an impact on clinical services.
Works with Quality Management in designing and evaluating protocols.
Ensures prompt and fair resolution of care management decision appeals.
Works with Provider Relations to enhance the working relationship between Community Care and the providers in its network.
Reviews proposed service denials and supervises care managers in the utilization of appropriate medical necessity criteria, and ensures appropriate care management integration and coordination.
Interfaces with physician consultants and provides direction for the physician consultants.
Implements quality management programs and continuing education activities.
Acts as a physician reviewer for cases referred by care management staff.
Works closely with the medical directors of physical health HMO's to assure coordination between physical health and behavioral health needs and services.
Acts as a liaison for Community Care with community physicians, hospital staff, and other professionals and agencies with regard to psychiatric services.
Assures effective and appropriate utilization of the various levels of care in the provider network.
Supports member satisfaction with the care management process
Minimum 10 years clinical experience.
Doctor of Medicine or Doctor of Osteopathy from an accredited school.
Unrestricted Licenseed in Pennsylvania.
Board Certification in Psychiatry, a second Board certification is helpful, but not required.
Experience in Behavioral Health treatment and program development.
Post residency clinical experience
At least 5 years of management experience preferred.
Experience in managed care setting preferred
Ability to implement medical policies, and to enforce those policies through appropriate action.
Ability to maintain effective professional liaison with all levels of executive and medical staff, including professional and institutional providers of care.
Ability to implement programs of quality care analysis, peer review, and professional education.
Quality of clinical care provided to COMMUNITY CARE members.
Effective and appropriate utilization of the various levels of care in the provider network.
Member satisfaction with the care management process.
Provider satisfaction with the care management process.
Meeting or exceeding NCQA standards and other applicable benchmarks.
Prompt and fair resolution of care management decision appeals.
Development and maintenance of effective relationships with providers.
Licensure, Certifications, and Clearances: Board Certification in Psychiatry
Doctor of Medicine (MD) OR Doctor of Osteopathic Medicine (DO)
Act 33 with renewal
Act 34 with renewal
Act 73 FBI Clearance UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities
Salary Range: $0 / hour
Union Position: No
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