Behavioral Health Medical Director - Psychiatrist Appeals

Behavioral Health Medical Director - Psychiatrist Appeals

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Behavioral Health Medical Director-Psychiatrist Appeals

Location: This role enables associates to work virtually full-time, with the exception of required in‑person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work‑life integration, and ensures essential face‑to‑face onboarding and skill development. Alternate locations can be considered. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Work schedule: Monday – Friday. Half day Saturday rotation, once a month.

The Behavioral Health Medical Director‑Psychiatrist Appeals is responsible for the administration of behavioral health medical services, to ensure the appropriate and most cost‑effective medical care is received. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities.

• Supports clinicians to ensure timely and consistent responses to members and providers.
• Provides guidance for clinical operational aspects of a program.
• Conduct peer‑to‑peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
• Serves as a resource and consultant to other areas of the company.
• May be required to represent the company to external entities and/or serve on internal and/or external committees. May chair company committees.
• Interprets medical policies and clinical guidelines. May develop and propose new medical policies based on changes in healthcare.
• Leads, develops, directs, and implements clinical and non‑clinical activities that impact health care quality cost and outcomes.
• Identifies and develops opportunities for innovation to increase effectiveness and quality.
• Provides oversight, direction, and guidance to Medical Director Associates.
• Works independently with oversight from immediate manager.
• May be responsible for an entire clinical program and/or independently performs clinical reviews.
• Typically has program management responsibilities including clinical policy development, improvement of quality, cost, and outcomes, program development/implementation, and overseeing clinical/non‑clinical activities.

• Requires MD or DO and Board certification approved by American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
• Must possess an active unrestricted medical license to practice medicine or a health profession.
• Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside the US.
• Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• For Health Solutions and Carelon organizations (including Behavioral Health) only, minimum of 5 years of experience providing health care is required.
• Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.

• Child and Adolescent experience preferred.
• Utilization Management experience.
• Applied Behavior Analysis (ABA) experience.
• An active unrestricted medical license to practice medicine or a health profession in California or ability to obtain upon hire.

For candidates working in person or virtually in the below location(s), the…