Determinations Medical Director, Behavioral Health at Bright Health
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Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.
SCOPE OF ROLE
The Bright Healthcare Behavioral Health Medical Director works with our Care Partners to facilitate coverage for a broad array of mental health and substance abuse disorders services. The Medical Director, Behavioral Health is a critical member of our coverage review and case management team. In collaboration with our non-MD clinicians, the right person uses their medical background, experience, and judgement to make determinations, whether requested services, requested level of care, and/or requested site of service should be authorized for coverage under the benefit plan. The Medical Director for Behavioral Health will also support peer to peer conversations for authorizations and appeals. Additional secondary responsibilities include contributing in all ways possible to increasing the value we provide to our members by managing the total cost of care, enabling Bright to offer equitable access to high quality and affordable care. This includes providing input and responding to the business needs related to network development, medical and payment policies, regulatory issues, overall program operations and other matters as arise from time to time.
This Medical Director, Behavioral Health roles responsibilities section is intended to point out major responsibilities within the role.
- Review determinations for medical necessity
- Support peer to peer conversations for authorization, appeals and concurrent review
- Participate in reviews of utilization by line of business and market
- Teach, mentor and learn from BEH team
- Support care management and care coordination for members and improve outcomes
- Support pharmacy and therapeutics committees and formulary development
- Report and advise on practitioner assessment and credentialling
- Support development of Mental Health parity process and other regulatory requirements
- Collaborate with the network team to improve network performance
- Contribute to policies as needed
- Other duties and responsibilities as assigned.
- This position does not have supervisory responsibilities.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Medical Doctor or Doctor of Osteopathy required.
- Board certification in Psychiatry required, with preferred additional experience or certification in addiction treatment.
- Five (5) years or more of clinical practice experience required. Administrative or managed care experience is highly desirable.
- An active, unrestricted Medical Doctor (MD) or Doctor of Osteopathy (DO) license to practice as a health professional in a state or territory of the United States is required. Licensure in Texas, Arizona and Illinois preferred.
- This position requires strong clinical knowledge to support review for medically appropriate utilization of medical services and case management.
- Excellent clinical and business judgement
- Independent and self-reliant
- Critical and creative thinking
- Strong interpersonal skills to generate collaboration and enable independent decision making amongst internal and external clinical staff
- Good communication skills with an ability to resolve conflict
- A drive to build, improve, and succeed
LICENSURES AND CERTIFICATIONS
- An active, unrestricted Medical Doctor (MD) or Doctor of Osteopathy (DO) license to practice as a health professional in a state or territory of the United States is required. Licensure in Texas, Florida, North Carolina, or Oklahoma preferred.
- Board certification in Psychiatry required, with preferred certification in addiction treatment.
- Remote with option to work in a nearby Bright Healthcare office, as applicable
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.