Behavioral Health Medical Director (Government Markets)

Location: Remote work from Pennsylvania, United States

Company

Highmark provides healthcare services and managed care programs.

What you will do

• Conduct utilization management reviews and provide clinical support for Medicaid, Medicare DSNP, and behavioral health pharmacy requests.
• Make decisions on member and provider appeals, grievances, and medically unnecessary services.
• Provide clinical input into care management, case management, behavioral health program development, network management, and quality initiatives.
• Analyze healthcare utilization and outcomes data, identify quality gaps, and develop corrective action and cost-saving plans.
• Collaborate with providers, network management, credentialing, quality improvement teams, senior leadership, and state regulators.
• Contribute to behavioral health strategy and the deployment of virtually integrated partnership models.

Requirements

• Doctorate degree.
• At least 5 years of experience as a behavioral health physician or addiction medicine physician.
• At least 3 years of medical staff leadership or healthcare management experience in managed care.
• At least 3 years of experience with formal quality and/or utilization management programs.
• Unrestricted Pennsylvania and West Virginia medical licenses, with the ability to obtain a Delaware license and additional state licenses as needed.
• Board certification in behavioral health, strong communication skills, and familiarity with state and federal regulations and NCQA requirements.

Nice to have

• Master’s degree in business administration, management, or public health.
• Professional utilization review or quality improvement certification.
• Seven years of experience as a behavioral health physician or addiction medicine physician.

Culture & Benefits

• Remote work arrangement.
• Collaboration across behavioral health, quality, network management, provider relations, and regulatory teams.
• Work focused on member satisfaction, quality outcomes, regulatory compliance, and cost-effective care.