Behavioral Health Medical Director - Clinical Appeals

CareSource Management Group Company

Job Overview

Location

Remote

Job Type

Full-time

Full Job Description

📋 Description

• Assume primary responsibility for the overall safety of patients with a behavioral health (BH) diagnosis, with a specialized focus on safe prescribing practices
• Serve as the clinical lead in developing, implementing, and revising evidence-based clinical policies, practice guidelines, and quality improvement initiatives
• Lead utilization management activities to determine behavioral health coverage, ensuring members receive appropriate, medically necessary care in the most cost-effective setting
• Provide oversight and quality improvement for case management activities, including review of clinical outcomes and member safety incidents
• Participate in regulatory and accreditation reviews for CMS, State agencies, NCQA, and URAC to ensure compliance with national quality standards
• Represent CareSource as the primary clinical liaison to members, providers, and state agencies on behavioral health matters
• Analyze healthcare data from multiple sources to identify variances in physician practice patterns and provide targeted feedback and education to MCP staff and providers
• Collaborate with market and product leaders to define strategic direction for behavioral health services and provider network development
• Support provider recruitment, orientation, and value-based contracting efforts to ensure full integration of behavioral health services
• Participate in investigations of suspected fraud, abuse, and quality of care concerns, providing clinical expertise to guide resolution
• Provide cross-coverage for other Medical Directors across markets as needed, including clinical consultation and case reviews
• Conduct Medical Advisement meetings and offer clinical training and support to staff to enhance clinical decision-making and member care
• Contribute to the development and revision of the Quality Improvement Plan and corporate-level quality initiatives aligned with nationally accepted standards
• Engage in community collaborations to advance behavioral health access and outcomes
• Maintain strict confidentiality, act with ethical integrity, and prioritize the company’s best interests in all clinical and operational decisions
• Apply critical listening, systematic thinking, and conflict resolution skills to navigate complex clinical and organizational challenges
• Demonstrate cultural sensitivity and diplomacy when engaging with diverse provider and member populations
• Perform additional job duties as assigned to support organizational goals and operational needs

🎯 Requirements

• Completion of an accredited Medical Degree (MD or DO)
• Successful completion of a psychiatry residency program
• Board Certification in Psychiatry
• Current, unrestricted medical license in the state of practice
• Minimum of three years of clinical practice experience
• Experience in safe prescribing

🏖️ Benefits

• Salary range of $195,200.00 - $341,600.00
• Bonus opportunity tied to company and individual performance
• Comprehensive total rewards package including health, wellness, and benefits
• Remote work environment

Skills & Technologies

Remote

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CareSource Management Group Company

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About CareSource Management Group Company

CareSource is a nonprofit, multi-state managed care organization headquartered in Dayton, Ohio. Founded in 1989, it administers Medicaid, Medicare Advantage, and Marketplace health plans serving over two million members in Ohio, Kentucky, Indiana, West Virginia, and Georgia. The company focuses on improving health outcomes for low-income and vulnerable populations through integrated care management, behavioral health services, and social determinants programs.

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