Job Details

Requisition Number 17-0111
Post Date 11/13/2017
Title Behavioral Health Medical Director
City Austin
State TX


The Medical Director functions as a physician advisor for the BH services and is responsible for the oversight of all utilization and case management activities. S/he participates in quality management activities for FirstCare as requested. The Medical Director works closely with the FirstCare Management Team and the Chief Medical Officer to establish and implement the necessary structures and processes to meet NCQA MBHO standards, and to establish, or adopt, and implement clinical practice guidelines. In addition, the Medical Director assists with the regular development, review and update of the level of care criteria. The schedule for the Behavioral Health Medical Director will be approximately 10 hours per week.


• Oversees Utilization Management and Case Management Programs

• Reviews medical care and service requests against established clinical guidelines and makes approval and denial determinations, in accordance with evidence-based standards, and organizational policies and procedures, and clinical judgment.

• Acts as first level physician reviewer for all cases referred by the Quality, Care Management Department, and Complaints & Appeals departments and sits in on 2nd level appeal hearings as necessary.

• Reviews, investigates and completes appeals related to medical necessity, appropriate level of service, and benefit coverage.

• Manages escalated and expedited member and provider appeals and complaints as required.

• Provides standard or expedited review and determination of both medical and pharmacy appeals/grievances for all line of business.

• S/he or his/her designee is available 24 hours/7 days a week to conduct telephonic clinical peer review

• Facilitates clinical discussion with providers for reconsiderations and appeals

• Conducts clinical review with care managers as needed

• Oversees Utilization Management Department to ensure level of care criteria are properly applied

• Participates in the development and annual (or more frequent, as necessary) review of level care criteria and clinical practice guidelines

• In conjunction with care management staff, develops clinical trainings and education for clinicians to promote development of solid clinical judgment

• Provides telephonic decision support to primary care providers and behavioral health clinicians

• Participates in NCQA and other accreditation processes

• Serves on committees as requested e.g., P&T, Credentialing, Quality Improvement.



• Medical Doctorate (MD/DO) required with Board Certification in psychiatry

• Active and current Texas medical license without encumbrances

• A minimum of five years clinical practice experience after completing residency training requirements

• A minimum of one years’ medical management or administrative experience, preferably in a managed care environment; utilization management and case management experience preferred

• Demonstrated excellence in collaborating with physicians and owner and limited partner leadership

• Demonstrated excellence in verbal and written communication skills

• Demonstrated effectiveness in leading committees and groups

• Demonstrated effectiveness in communicating and implementing policies and programs

• Computer skills with basic understanding of Microsoft Word, Excel and PowerPoint

FirstCare Health Plans is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetics or any other basis prohibited by law.

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