Medical Director, Behavioral Health (Part Time)

Blue Shield of CA; Springfield Meadows (CA); Hybrid; USD 250,000 - 360,000; Full time

Job summary

Blue Shield of CA is seeking a Medical Director, Behavioral Health in California to lead behavioral health concurrent review and utilization management. You will collaborate with Clinical Care Managers to improve care quality and ensure regulatory compliance.

The role requires a medical degree, psychiatry residency, and board certification, with a strong background in managed care and behavioral health services.

Qualifications

• Medical degree (M.D./D.O.) required.
• ACGME accredited residency in Psychiatry required.
• Minimum 5 years direct patient behavioral health clinical care experience post residency required.
• Active California Medical License (unrestricted) required; license in other states required.
• Board Certification in Psychiatry (ABPN or AOBNP) required.
• Recent inpatient psychiatric hospital experience preferred.
• Substance use disorder treatment experience preferred.
• Strong knowledge of behavioral health services and conditions.
• Ability to make rapid, accurate decisions and resolve complex issues.
• Experience with CPT coding, medical claims review, and reimbursement strongly preferred.
• Knowledge of MHPAEA, SB855, regulatory and compliance requirements preferred.
• Managed care experience in utilization management and quality improvement preferred.
• Experience with ASAM, LOCUS, CALOCUS preferred.

Responsibilities

• Oversee behavioral health concurrent review and utilization management.
• Lead pre- and post-service utilization reviews and case reviews.
• Collaborate with Clinical Care Managers to improve care quality.
• Ensure compliance with applicable regulations and parity acts.
• Provide strategic leadership and develop high-performing teams.

Skills

Medical leadership

Behavioral health expertise

Utilization review experience

Decision-making

Regulatory compliance

Education

Medical degree (M.D./D.O.)

ACGME Psychiatry residency

Tools

CPT coding

Medical claims review

Hospital billing

Job description

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Behavioral Health will report to the Senior Medical Director, Behavioral Health. In this role you will have core responsibilities in the areas of behavioral health concurrent review, pre- and post-service utilization review, and collaboration with Clinical Care Managers. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Knowledge and Experience

• Medical degree (M.D./D.O.) required


• Completed an ACGME accredited residency in Psychiatry required


• Minimum 5 years direct patient behavioral health clinical care experience post residency required


• Maintain active, unrestricted California Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required


• Maintain Board Certification in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP) required


• Recent inpatient psychiatric hospital experience (within the past five years)- preferred


• Recent substance use disorders treatment experience (within the past five years) preferred


• Well-versed with most areas of behavioral health services and conditions


• Show ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issues


• Experience with CPT coding, medical claims review, hospital billing, and reimbursement is strongly preferred


• Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855 and all regulatory and compliance requirements is strongly preferred


• Managed care experience supporting utilization management, case review, and/or quality improvement activities in behavioral health is strongly preferred


• Experience with ASAM, LOCUS, and CALOCUS is strongly preferred

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.