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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Responsibilities:
The Medical Director, Substance Use Disorder and Behavioral Health (Med. Dir. SUD/BH) provides organizational leadership and clinical oversight and direction for the substance use disorder (SUD) and behavioral health (BH) components of the Medical Management Programs. The Med. Dir. SUD/BH will have responsibility for the design of programs in compliance with federal and state laws and contractual requirements. At the request of BHM, this position will provide local physician review of SUD and BH treatment requests. The Med. Dir. SUD/BH will make recommendations regarding ACNH utilization management programs based on member and provider needs and feedback. The Med. Dir. SUD/BH will report to the Market President and work closely with the Chief Medical Officer, Director of Population Health, and appropriate staff to ensure that AmeriHealth Caritas New Hampshire’s substance use disorder and behavioral health care management, utilization management and quality management programs comply with the terms of the State contract requirements and are supported by evidence-based practices.
The following responsibilities are in regards to members with diagnosed mental illness and substance abuse conditions and their providers:
- Identifying and implementing evidence-based practice guidelines throughout the provider network.
- Overseeing the quality of clinical care for network and non-network providers.
- Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards, and through an internal quality assurance program that measures network provider performance against standards of high quality, especially the performance standards embodied in the HEDIS program.
- Reviewing and resolving disputes related to the quality of care.
- Assuring a high-performing Utilization Management system that adheres to the coverage terms and requirements of the contract. The system will utilize evidence based standards in making coverage determinations in individual patient cases that appropriately apply standards to specific cases.
- Serve as the primary external subject matter expert for ACNH for SUD and BH, including working with regulators, legislators, community organizations and providers.
- Lead the development and implementation of contractually required clinical programs, such as emergency room boarding of members with a behavioral health treatment need.
- As requested by BHM, participate in the review of denials of care for SUD and BH treatment services.
Additional Accountabilities
- Ensure the provision of quality and clinically sound SUD and BH services to all Members by associates and Providers.
- Serves as clinical advisor and manager for all clinically related SUD and BH activities.
- Assures that organization policies and procedures adhere to contractual obligations.
- Performs clinical case reviews in conjunction with Medical Management Department.
- Demonstrates knowledge of prescribed and established procedures and practices.
- Maintains familiarity with federal, state and local regulations that may pertain to the medical and clinical operations.
- Participate in Complaint and Grievance processes related to service denials and clinical practices.
- Participate with Quality Improvement and Medical Management in the identification and analysis of clinical information in order to develop interventions to improve effectiveness of ACNH SUD and BH programs.
- Attend case management meetings and monthly rounds as required by DHHS.
- Champion continued integration of SUD and BH with medical programs to improve integration of BH and SUD in the primary care environment.
- Adhere to AmeriHealth Family of Companies (ACFC) policies and procedures; support and carry out the ACFC Mission and Values.
- Perform other related duties and projects as assigned.
Education/ Experience:
- MD required.
- Valid NH medical license; board certification in psychiatry and addiction psychiatry preferred.
- Board Certified Addictionologist in New Hampshire.
- Must have unrestricted licensed to practice in the state(s) assigned as a medical director/doctor and recognized by the proper licensing authority.
- Must be clear of any sanctions by the applicable state or Office of the Inspector General.
- Must not be prohibited from participating in any Federally or State funded healthcare programs.
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Diversity, Equity, and Inclusion
At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
We keep our associates happy so they can focus on keeping our members healthy.
Our Comprehensive Benefits Package
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
