Medical Director - Behavioral Health - ABH OH

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

This is a remote-based (work from home) role. Candidates residing in Ohio are preferred.

Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. 

In this role as Medical Director (Behavioral Health), you will:

• Provide leadership and day-to-day physician oversight for utilization management team, including the management of high-risk cases and medical necessity decisions

• Provide comprehensive behavioral health care management to facilitate delivery of appropriate quality care and improve program/operational efficiency involving clinical issues

• Participate in the appeals process, including the investigation of adverse events and quality of care concerns

• Provide psychiatric leadership to an interdisciplinary utilization management team, including medical/clinical oversight, consultation and training

• Provide day-to-day physician oversight including management of high-risk cases throughout treatment/levels of care and medical necessity decisions

• Assist with the development, implementation, monitoring and evaluation of the utilization management program and action plan, ensuring quality and appropriateness of care

• Assist with the development, implementation and interpretation of medical policy including medical necessity criteria, clinical practice guidelines and new technology assessments

• Participate in the development, implementation, and evaluation of clinical/medical programs

• Confer with behavioral health practitioners regarding the care of patients with severe, complex and/or treatment resistant illnesses

• Identify and address quality of care concerns with providers involved in a member's care

• Provide psychiatric leadership for NCQA-compliant clinical quality improvement activities in collaboration with clinical and quality improvement staff

• Participate in the triage and referral for care management

• Provide weekend coverage every 6-7 weeks.

• Perform other duties as deemed necessary.

• Board-certified Psychiatrist currently licensed in the State of Ohio or with the ability to become licensed in the State of Ohio

• Active and current state medical license without encumbrances, and ability to obtain other state licenses.

• This role requires the ability to get additional state licensures and provide UM coverage across multiple different state health plans. 

• MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine)

The typical pay range for this role is: