The client is seeking a Behavioral Health Medical Director to focus primarily on adult psychiatric cases related to substance abuse. This is a part-time role with a flexible schedule. The Medical Director will review 12–15 cases during each 4-hour shift, delivering accurate clinical assessments and determining coverage in accordance with internal policies, regulatory standards, and accreditation requirements.
Key responsibilities include conducting coverage reviews based on member plan benefits and review policies, documenting clinical review findings, actions, and outcomes in compliance with applicable requirements, and using established clinical guidelines (including Interqual and ASAM) to support review decisions. The role also involves interpreting benefit language and policies, performing assessment and decision-making for appeals and grievances with review-level separation, and engaging with requesting providers through peer-to-peer discussions when needed.
The Medical Director will collaborate with network and non-network providers to support timely and accurate benefit determinations, including educating providers on benefit plans and medical policies. The position is expected to support organizational quality efforts and accreditation and regulatory review processes across utilization management functions such as prior authorization, concurrent review, and case management, while maintaining current knowledge of emerging treatment modalities and relevant standards. Qualifications include 5+ years of post-residency clinical experience and 3+ years of experience in managed care, utilization review, or quality management, along with an MD or DO degree, board certification, and current unrestricted medical licensure in Pennsylvania with medical liability coverage or eligibility.