Behavioral Health Medical Director (Government Markets)

TL;DR

Behavioral Health Medical Director (Government Markets): Managing clinical consultation and support for behavioral health and addiction services within government markets with an accent on utilization management and regulatory compliance. Focus on optimizing quality and cost-effective care, resolving provider appeals, and directing strategic delivery system transformation.

Location: Remote (USA), must hold unrestricted PA and WV Medical Licenses

Company

hirify.global is a leading healthcare corporation specializing in managed care and behavioral health services for government markets.

What you will do

• Perform utilization management reviews and provide clinical support for Medicaid and Medicare (DSNP) membership.
• Manage member and provider appeals and grievances, including ALJ and SFH cases.
• Provide clinical input for care and case management, clinical program development, and network management.
• Collaborate with state regulators (PA DHS, PA OLTL, & WV BMS) and internal quality teams to address HEDIS and NCQA metrics.
• Analyze healthcare data to evaluate clinical initiatives and implement cost-saving strategies.
• Review provider applicants and make credentialing decisions according to NCQA standards.

Requirements

• Doctorate Degree and Board Certification in Behavioral Health.
• Unrestricted PA and WV Medical Licenses (ability to obtain DE license).
• 5+ years of experience as a Behavioral Health or Addiction Medicine Physician.
• 3+ years in medical staff leadership or healthcare management within Managed Care.
• 3+ years of experience with Formal Quality and/or Utilization Management programs.
• Must be based in the United States.

Nice to have

• Master's Degree in Business Administration, Management, or Public Health.
• Professional UR/QI certification.
• 7+ years of experience as a Behavioral Health or Addiction Medicine Physician.

Culture & Benefits

• Opportunity to work within a large-scale corporate structure.
• Role in the delivery system transformation team.
• Remote work options.
• Collaboration with state and federal agencies.