Assistant Medical Director- Behavioral Health Focus (.5 Part Time)

Premera; Mountlake Terrace, Orcas (WA, WA); Vor Ort; USD 215.000 - 386.000; Teilzeit

Benefits dieser Stelle

Medical, vision, dental coverage

Tuition assistance

Retirement plan (401K)

Zusammenfassung

Premera is seeking an Assistant Medical Director (psychiatry) to perform clinical reviews and determine coverage based on medical necessity and policy. The role supports disease and case management, and collaborates with nursing and other staff to explore care options for members.

This is a part-time position at 20 hours per week. Required credentials include an MD or DO, unrestricted WA/AK licensure (or ability to obtain), and board certification in psychiatry with five years of clinical

Qualifikationen

• Must hold MD or DO with unrestricted license in WA or AK or ability to obtain in 90 days.
• Current board certification in psychiatry required.
• Minimum five years of clinical psychiatry experience; health plan reviews preferred.

Aufgaben

• Perform clinical review of case types including pre-, post-, and concurrent behavioral health services.
• Act as final decision maker for coverage based on medical necessity and contract terms.
• Support peer-to-peer discussions with external physicians and collect clinical history.
• Participate in the development and annual review of medical review criteria.

Kenntnisse

Clinical review

Medical policy

Communication with physicians

Team collaboration

Ausbildung

MD or DO degree

Board certification in Psychiatry

Tools

CPT

ICD

RBRVS

Jobbeschreibung

Workforce Classification: Telecommuter Join Our Team: Do Meaningful Work and Improve People’s Lives Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare. Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace. Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com/.

As the Assistant Medical Director, you will provide benefit coverage determinations based on medical necessity and contract language for health plan members, including a review of clinical documentation using medical policy criteria, guidelines, and member contracts at Premera Blue Cross. The Assistant Medical Director supports clinical programs (disease and case management), and the review and adoption of health plan developed review criteria.

What you will do:

• Perform clinical review of various case types as assigned. These may include pre-service, post-service, and concurrent behavioral health services, which may be outpatient or facility based.
• Consult with clinical staff on specific case reviews.
• Act as the final decision maker for coverage decisions based on medical necessity, investigational status, other contractual exclusion, or network structure.
• Support the peer-to-peer discussion process by communicating with external physicians and providers about denial determinations and collecting additional clinical history pertinent to case determinations.
• Consult with nursing and other clinical staff to assess and explore care options for members enrolled.
• Participate in the development, annual review, and approval of company medical review criteria as a Premera Medical Policy Committee member.
• Participate in Inter-Rater Reliability evaluations to ensure consistency in clinical decision-making.
• Respond in a professional manner to all requests for consultation from within Premera Blue Cross and from contracted practitioners and facilities.
• Support member and provider appeals by participating in the appeals process and conducting secondary reviews as needed.
• Fulfill all professional continuing education requirements and participate in ongoing education/training as appropriate.
• This role will be part-time, 20 hours a week.

What you will bring:

• Licensed Physician with an MD or DO degree (Required)
• Unrestricted Washington MD or Alaska DO state licensure, or ability to obtain within 90 days.
• Current board certification in psychiatry from the American Board of Psychiatry and Neurology.
• Five (5) years of clinical experience in psychiatry (Required)
• Previous experience performing medical necessity and clinical reviews in a health plan setting. (Preferred)
• Familiarity or experience with clinical criteria sets and clinical pathways, such as MCG (Milliman Care Guidelines) or InterQual. (Preferred)
• Familiarity or experience with CPT, ICD, and HCPCS code sets and resource-based relative value scale (RBRVS) pricing concepts. (Preferred)

This role will be part-time, 20 hours a week.

What you will bring:

• Licensed Physician with an MD or DO degree (Required)
• Unrestricted Washington MD or Alaska DO state licensure, or ability to obtain within 90 days.
• Current board certification in psychiatry from the American Board of Psychiatry and Neurology.
• Five (5) years of clinical experience in psychiatry (Required)
• Previous experience performing medical necessity and clinical reviews in a health plan setting. (Preferred)
• Familiarity or experience with clinical criteria sets and clinical pathways, such as MCG (Milliman Care Guidelines) or InterQual. (Preferred)
• Familiarity or experience with CPT, ICD, and HCPCS code sets and resource-based relative value scale (RBRVS) pricing concepts. (Preferred)

#LI-SS1 Premera total rewards

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being.

• Medical, vision, and dental coverage with low employee premiums.
• Voluntary benefit offerings, including pet insurance for paw parents.
• Life and disability insurance.
• Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.
• Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.
• Generous paid time off to reenergize.
• Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.
• Employee recognition program to celebrate anniversaries, team accomplishments, and more.
• For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.
• Commuter perks make your trip to work less impactful on the environment and your wallet.
• Free convenient on-site parking.
• Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.
• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
• Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
• Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.

Equal employment opportunity/affirmative action: Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law. If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at [e-mail] or via phone at 425-918-4785.

Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience. The salary range for this role is posted below; we generally target up to and around the midpoint of the range. National Salary Range: $214,500.00 - $386,100.00 National Plus Salary Range: $214,500.00 - $386,100.00 *National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska. We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all.

We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions. At Premera, we make healthcare work better. By focusing on improving our customers’ experience purposefully and serving their needs passionately, we make the process easier, less costly, and more positive. Through empathy and advocacy, we change lives. As the leading health plan in the Pacific Northwest, we provide comprehensive health benefits and services to more than 2 million customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, vision, dental, disability, and other related products and services. Premera Blue Cross is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise.