Point32Health

External Provider Relations and Provider payment reviews including payment integrity. Voting member of Committees like Appeals, Medical Technology and Medical Policy Approval, to help inform organization's decisions for benefit coverage.. Performs utilization management activities in accordance with accreditation standards and regulatory guidelines described in legacy Tufts Health Plan or Harvard Pilgrim Health Care UM Policy and Procedure Manual.. Render medical necessity coverage determinations in accordance with legacy Tufts Health Plan or Harvard Pilgrim Health Care Medical Necessity Guidelines and the member's EOC / benefit document.. Render/provide appeal decisions following legacy Tufts Health Plan or Harvard Pilgrim Health Care claims payment policies

behavioral health

Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.
Job Summary
The Medical Director, Behavioral Health is a seasoned physician and a key member of the CMO organization as well as Behavioral Health department leadership team and responsible for these predominant scopes of work pertaining to Behavioral Health:
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Clinical Program Leadership and Consultation
</li>
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External Provider Relations and Provider payment reviews including payment integrity
</li>
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Medical Management, Care Management, Quality & Medical Policy, and other Medical Director responsibilities
</li>
</ol>
This role requires an individual with the ability to form close working relationships with key internal and external stakeholders and to demonstrate a high level of knowledge about clinical issues while also understanding key business goals for all products. The Medical Director, Behavioral Health will closely collaborate with each Enterprise function in delivering on the clinical goals of the divisions. The position will report directly to the Vice President and Senior Medical Director in the Office of the CMO and will work closely with vice presidents and directors throughout the organization.
Additional functions could include prospective, concurrent, and retrospective utilization reviews including member- facing initial reviews and appeals. They will work closely with staff from all partner UM, Medical Management Departments on these review activities. They will also work with other departments including Claims Operations, Actuarial, and Quality Management and could assist with performing clinical reviews of provider claims payment disputes, perform retrospective claims audits of medical records, review of potential quality of care issues as well as credentialing of Providers and Facilities.
Essential functions may occur simultaneously, therefore, the Medical Director, Behavioral Health must be able to appropriately handle each essential function, prioritize them and seek assistance when necessary. The expectation is for these functions to be performed on a consistent and regular basis, using good judgment. Ability to learn and apply company policies consistently, seeking out guidance, when necessary, will be of utmost importance.
Key Responsibilities/Duties - what you will be doing
Provider/Quality Collaboration Programs
<ul>
<li>Develop strategic alliances through coordinated clinical programs, contractual agreements, established joint venues and provider notifications that engage providers to promote high quality, cost-efficient care.</li>
<li>Work closely with teams focused on provider performance to promote actionable reporting and metrics for provider performance improvement.</li>
<li>Engage providers as needed to improve clinical metrics such as cost, utilization, and quality.</li>
<li>Understand and suggest Network options for improving access and performance for provider groups.</li>
<li>Work closely with Point32Health Quality Department to understand and improve quality metrics.</li>
<li>Work with Directors and other leaders and inform strategies to meet Accreditation Goals, HEDIS performance metrics, PIPs QIPS to improve quality of care and meet performance goals.</li>
<li>Support team by informing internal review of Occurrences, and support Credentialing/QOCC as needed by identifying thresholds for quality concerns.</li>
<li>Voting member of Committees like Appeals, Medical Technology and Medical Policy Approval, to help inform organization's decisions for benefit coverage.</li>
<li>Support Delegation/Designation Oversight of Delegated Vendor Relationships 50%</li>
</ul>
BH Clinical Programs/Utilization Management & Case Management:
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<li>Collaborate with other key enterprise stakeholders to identify and execute on areas of amenable to improvement</li>
<li>Assist with implementation and operationalizing of Medical Cost Management strategies as related to Behavioral Health Programs</li>
<li>Collaborate with case managers and utilization managers in identifying and implementing alternative services as appropriate to an individual members plan of care</li>
<li>Enhance analysis and member engagement process for high-cost claimants/outliers</li>
<li>Work with clinical teams and providers to ensure successful results on performance expectations</li>
<li>Understand and assist with developing and monitoring clinical performance expectations</li>
<li>Act as liaison and collaborative clinical thought-leader to internal and external care management and transitions of care programs</li>
<li>Serve as physician provider liaison for case management teams, meeting with decision makers in the provider community, convening interagency case conferences to improve and implement plans of care</li>
<li>Promote an understanding of regulatory requirements for coverage as, as well as attend key meetings related to appeals of services denied to members</li>
<li>Serves as liaison to LOB CMOs and enterprise Medical Management director team</li>
<li>Provide coaching, feedback and direction to ensure the successful achievement of business and professional goals.</li>
</ul>
40%
Clinical Innovation
<ul>
<li>Help inform Organization's approach to innovation solutions in the Behavioral Health Space</li>
</ul>
10%
Qualifications - what you need to perform the job
EDUCATION and EXPERIENCE: (Minimum educational qualifications)
<ul>
<li>Candidate will be an American Board of Psychiatry and Neurology Board-Certified MD or DO in Psychiatry.</li>
<li>Minimum of five years of clinical experience is required.</li>
<li>Utilization management, quality and / or management experience, either at another health plan or at a local provider unit, medical group, or health care facility is preferred.</li>
<li>They are required to have a current unrestricted license as a medical or osteopathic doctor in Massachusetts.</li>
</ul>
SKILL REQUIREMENTS: (Includes interpersonal skills)
<ul>
<li>Performs utilization management activities in accordance with accreditation standards and regulatory guidelines described in legacy Tufts Health Plan or Harvard Pilgrim Health Care UM Policy and Procedure Manual.</li>
<li>Render medical necessity coverage determinations in accordance with legacy Tufts Health Plan or Harvard Pilgrim Health Care Medical Necessity Guidelines and the member's EOC / benefit document.</li>
<li>Render/provide appeal decisions following legacy Tufts Health Plan or Harvard Pilgrim Health Care claims payment policies</li>
<li>Have an understanding of principles of utilization management and quality assurance.</li>
<li>Have the skills to communicate with and educate Point32Health peers as well as Tufts Health Plan or Harvard Pilgrim Health Care participating physicians in a collegial manner.</li>
<li>Be an effective team player, with excellent interpersonal, cross-departmental and leadership skills.</li>
</ul>
<h3>LI-Remote</h3>
<h3>LI-DH1</h3>
Compensation & Total Rewards Overview
The annual base salary range provided for this position represents a broad range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; equity with internal colleagues; and other conditions of employment. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.
<h3>Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes</h3>
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Medical, dental and vision coverage
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Retirement plans
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Paid time off
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Employer-paid life and disability insurance with additional buy-up coverage options
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Tuition program
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Well-being benefits
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Full suite of benefits to support career development, individual & family health, and financial health
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</ul>
For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/
Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity
Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do-from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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