Responsible for providing the clinical leadership for behavioral health in the assigned market. Provides direction and management of behavioral health staff located in assigned market; staff may include Behavioral Health Concurrent Review, Case Management, and Provider Relations. Responsibilities also include improvement of clinical outcomes and quality improvement, while improving the consumption health care resources in accordance with WellCare corporate objectives.
Incumbent oversees all clinical aspects of behavioral health, and helps establish policy and procedures for behavioral health, including its integration with medical care and pharmacy. Incumbent will serve as a key representative and spokesperson with respect to the external behavioral health community in the market. Incumbent will help lead a continuing improvement of the network delivery system in the market, including working collaboratively with providers to encourage development of new and more community-based types of care and better integrating behavioral health with physical health and social services.
- Provides overall clinical leadership in behavioral health for the assigned market.
- Responsible for overseeing all clinical aspects of behavioral health, including care and utilization management, network and provider relations, quality improvement, health IT, and overall administration including legal and finance.
- Responsible for overseeing and ensuring integration of behavioral health into all functional areas of the health plan, and working collaboratively with corporate behavioral health and medical staff to implement integrated policies and procedures. Provides reliable assistance to the assigned market medical director and clinical staff to assure effective integration of behavioral services into health plan medical management activities.
- Works closely with the assigned market's senior leadership to assure clinical compliance with all company, customer and regulatory requirements for behavioral services.
- Helps establish policy and procedures for behavioral health, including its integration with medical care and pharmacy.
- Acts as thought-leader for behavioral health, and will provide teaching, training, coaching, and supervision of internal staff.
- Leads behavioral health medical management initiatives for assigned market to include utilization management, concurrent review, pharmacy management, and case management through a matrix partnership with the market president regional medical director, director of behavioral health operations, case management field director and field case management staff.
- Has shared responsibility for Quality Improvement & accreditation initiatives in the assigned market.
- Reviews provider and member complaints, assists in resolution, and makes recommendations for changes.
- Responsible for provider education regarding best clinical practices, pharmacy utilization, quality improvement and responsible health care expenditure to improve clinical outcomes.
- Provides leadership for various corporate and local initiatives as assigned.
- Assists in the interpretation of medical policy for associates to facilitate the healthcare and behavioral health needs of our members.
- Works closely with P&L owners to develop strategies to change member and provider behavior to improve quality of care and clinical outcomes.
- Helps lead a continuing improvement and evolution of the delivery system in the assigned market, including working collaboratively with providers to encourage development of new and more community based types of care and better integrating behavioral health with physical health and social services.
- Works closely with and influences key business partners within a matrix organization faced with competing priorities.
- Makes recommendations (based on daily activities of evaluating members' care) about medical policy, clinical criteria and administrative process.
- Participates on medical policy, credentialing and related health plan committees as required or assigned. Chairs behavioral health Clinical Advisory Committee in assigned market.
- Works with the local behavioral health and medical community to assist in the development and maintenance of a strong, quality network of providers.
- Visits targeted providers for recruitment, as well as performing proactive provider visits on a regular basis.
- Manages and develops direct reports who include directors and/or managers.
- Provides subject matter expertise to support operations, product development, and growth initiatives.
- Works collaboratively with matrix partners, business development, and market leadership to deliver clinical programs that support the business objectives of the market.
- Works collaboratively with the team based in the assigned market as well as the corporate staff in Tampa FL.
- Develops value propositions for clinical programs through quantitative analytics, ROI, and evidence-based data.
- Participates in the identification and analysis of medical information from multiple sources in order to develop interventions to improve the quality of care and outcomes.
- Creates a motivated customer-service driven environment.
- Provides leadership, oversight, direction and guidance of behavioral health operations in Health Services clinical management. Ensures that activities are carried out in a timely manner.
- Develops and manages activities to ensure compliance with Federal, State, and NCQA accreditation standards.
- Oversees and participates in Performance Improvement Activities.
- Represents WellCare Health Services at various meetings and conferences on an ongoing basis.
- Recognizes and observes all company and departmental policies and procedures.
- Focuses on achieving market, departmental and organizational objectives.
- Maintains professional appearance and executive presence by complying with dress code in an appropriate manner.
- Complies with company policies and procedures.
- Performs additional duties and responsibilities as assigned by management.
- A MD or DO degree from an accredited medical school and board certification.
- Current license without restrictions in working state or the ability to obtain that license if necessary and ability to acquire license in multiple states.
- At least five years of clinical practical experience.
- At least three (3) years of experience and knowledge of the managed behavioral healthcare industry, Medicare and Medicaid experience preferred.
- Demonstrated expertise in Behavioral Health Services, such as prior authorization, intake, concurrent review, case management, discharge planning including development and management.
- Experience or familiarity with NCQA accreditation.
- Negotiation and conflict resolution skills as needed.
Communication and Numeric Skills:
- Excellent oral and written communication skills to multiple audience levels, including senior management, external customers, and members.
- Strong analytic, financial, and budget planning skills.
- Knowledge of email systems such as Microsoft Outlook sufficient to communicate with both internal and external contacts.
- Knowledge of Word and/or Excel sufficient to enter data, copy or cut and paste data and print results as required.