Medical Director - Behavioral Health - Inland Empire Health Plan

1. Provides overall clinical leadership and develops and implements clinical policies for the IEHP Behavioral Health Program.  This includes delivery of mental health services, substance use services, medication management, and coordination of behavioral health services and primary care.
2. Provides direction of current clinical practices for behavioral health services.  Ensures that qualified medical/clinical personnel render clinical decisions regarding behavioral health, unhindered by fiscal or administrative management, and consistent with regulatory requirements and UM guidelines.
3. Leads Behavioral Health quality improvement efforts while helping to manage health plan medical costs, assuring an appropriate and efficient health care delivery system for IEHP Members, and supporting IEHP strategic goals.
4. Monitors performance of behavioral health providers and leads performance improvement efforts in the network to improve the quality of services delivered to IEHP members in collaboration with IEHP leadership..
5. Leads efforts to further integrate substance use treatment into the care delivery system, including implementing integrated care models that increase access to Medication Assisted Treatment (MAT) along with substance use counseling and other evidence-based addiction interventions.
6. Develops targeted education, training, and clinical guidance to contracted primary care physicians (PCPs) treating behavior health-related concerns not requiring referral to behavior health specialists.
7. Provides medical direction and guidance to the Behavioral Health Department in the arena of inpatient, outpatient pre-service authorizations and utilization management, including the coordination of care with external agencies, consultation on complex cases, and participation in Interdisciplinary Care Teams/case conferences
8. Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality, cost, and outcomes.
9. Reviews cases and ensures appropriate adjudication of prior authorization.  Directly reviews all medical necessity denials and modifications of a prior authorization requests.
10. Ensures the creation, modification, and appropriate and timely use of UM criteria for both inpatient and outpatient authorizations.
11. Identifies and develops opportunities for innovation to increase effectiveness and quality.
12. Ensures that assigned patients have access to behavioral health services coordinated with primary and specialty care throughout IEHP’s geographic coverage area.  Partners with the Contracting Department to ensure a full and appropriate primary and specialty behavioral health care provider network for Members.
13. Consults on written protocol for IEHP behavioral health providers to ensure adherence to standards and quality of care.  Coordinates professional interactions among practitioners and lends assistance toward correcting any deviation from standards. Develops relationships with directly contracted behavioral health providers.
14. Reviews State mandated benefits to ensure the IEHP Behavioral Health Program is in full compliance through its providers.
15. Partners with Behavioral Health leadership in curriculum development designed to promote a comprehensive, effective, and equitable behavioral health program.
16. Any other duties as required ensuring Health Plan operations are successful.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.