Gateway Health Llc
Job Description :
This job plays a crucial role in the corporation’s success, and under direction by the chief medical officer and in collaboration with the senior director for behavioral health, works closely with all divisions and departments within the corporate structure to provide clinical consultation and support with regard to the behavioral health and addiction services program strategy and development, compliance with accepted medical standards, and practitioner/provider education. The incumbent is an integral part of the behavioral health utilization management team and assists utilization management staff by direct supervision or as otherwise appropriate to ensure delivery of quality and cost–effective care, member/provider satisfaction, and quality outcomes.
Provide utilization management reviews and clinical support for Medicaid, Medicare (DSNP) membership and Behavioral Health Pharmacy requests; communication of the decisions to the member and provider.
Provide clinical input into healthcare management services’ activities relating to behavioral health and addiction medicine, including for example, care and case management, clinical program development, and network management.
Working with the network management and provider relations teams, act as a liaison for Gateway with practitioners/providers through ongoing communications and monitoring of services utilized.
Contribute to development of the strategic direction for behavioral health for GHP as a member of the delivery system transformation team, help direct deployment and management of the virtually integrated partnership model.
Serve as a resource for information and consultation on the issues related to utilization management, clinical services and medical affairs, including such issues as case management, disease state management programs, health risk assessments or other topics of general interest.
Analyze utilization data and various forms of health care data available within and external to the corporation to evaluate effectiveness of clinical initiatives and care and case management processes. Identify factors for below quality standards and intervene as the spokesperson with local practitioners/providers to resolve care and case management issues and participate in the development of long-term strategies to create cost-effective medical care.
Monitor clinical resource allocation, utilization and referral patterns, patient satisfaction, and clinical outcomes across the practitioner and provider network and at times make denials of services based on the absence of medical necessity.
Provide findings to senior leadership and lead development of corrective action plans as indicated.
Work with the credential staff to review provider applicants and to make decisions regarding approval, denial, and/or terminations according to Gateway’s policies and NCQA standards. Develop a working knowledge of the credentialing process and criteria and participate in its design.
Regionally supervise and/or collaborate the activities/directives of the QI operations staff and committees. Attend corporate QI committee meetings, and report on regional actions related to committee function.
Provide clinical oversight of clinical consultants who provide assistance with the evaluations of ancillary services (physical, occupational therapy, speech therapists; DME consultant and prosthetist); manage their budgets.
Other duties as assigned or requested.
5 years as a Behavioral Health Physician OR Addiction Medicine Physician
3 years in a medical staff leadership or healthcare management role in Managed Care
3 years with Formal Quality and/or Utilization Management programs
LICENSES or CERTIFICATIONS
Proven ability to manage a project in order to accomplish established goals within a reasonable time period and through the use of developed organization and leadership skills
Excellent communication and public speaking skills, well-developed interpersonal skills, and ability to interact effectively with members, practitioners/providers, colleagues, and local State and Federal agencies
Familiarity with applicable State and Federal regulations and NCQA requirements for accreditation
Language (Other than English):
0% – 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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