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HARP Medical Director

Job Ref: 59033
Category: Professional
Location: 160 Water St. #3, New York, NY 10038
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $230,000.00
Salary Range: $230,000.00 - $250,000.00

About NYC Health + Hospitals

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview

Responsible and accountable to the Deputy Chief Medical Officer for helping to manage health plan behavioral health quality and costs and assuring appropriate health care delivery. The Associate Medical Director serves in policy, operational and strategic capacities. The Associate Medical Director has over all accountability for
behavioral health services for HARP plan enrollees. This is a broad function that includes day to day operations, data and reporting design and high-level strategy, planning and policy involvement.

Job Description

  • VSupport the maintenance of clinical protocols and policies to enhance the quality of medical necessity decision-making, incorporating input from the clinical review team, operations, and other medical operations leads such as the OMH / OASAS State Medical Directors forums.
  • Support the use of integrated care models such as collaborative care model for treating conditions in primary care.
  • Conduct analyses to identify trends and patterns suggestive or indicative of:
  • Inappropriate, unreasonable, medically unnecessary care; inappropriate transfers; and Insufficient, poor documentation or patterns of failing to provide medical records.
  • Chair the Case Management / Utilization Management HARP quarterly Subcommittees.
  • Supervise retrospective review of claims to identify practice patterns that could be improved to reduce costs and improve care.
  • Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and outcome decisions, including feedback on alternate treatment based on medical necessity criteria.
  • Promote medical necessity determinations that consider level of need as well as environmental factors, available resources, and psychosocial rehabilitation standards.
  • Develop a working familiarity with applicable SUD regulatory standards based on the OASAS LOCADTR tool.
  • Understanding of specialized expertise for assessment, treatment and management of special population, including older adults, transition age youth (TAY), individuals with co-occurring disorders, individuals experiencing first episode of psychosis (FEP) individuals with SMI and criminal justice or assisted outpatient treatment (AOT) involvement and individuals with SMI and /or functionally limited SUDs.
  • Oversee the development of evidence based clinical best practices, policies, and practices.
  • Participate as a member of Interdisciplinary Care Teams (ICT) that ensures an integrated model of care approach for the designated population(s); work with other medical representatives of ICTs to ensure a consistent and high value approach to team processes
  • Sole authority and responsibility for assuring that clinical adverse determinations are based on medical necessity.
  • Work collegially with Senior Director of BH to identify trends, problems, and opportunities, including conduct root cause analysis.
  • Shares accountability with Senior Director of BH in meeting NCQA requirements for UM CM and operations.
  • Work closely with the corporate medical policy team for clinical input and formulation of BH policies and protocols.
  • Perform other duties as needed and assigned by the Chief Medical Officer/ DCMO

Minimum Qualifications

  • Board Certified Adult Psychiatrist with active New York license or certification to practice medicine without restriction required (MD or DO required)
  • Minimum of 5 years of experience working in BH managed care setting and/or BH clinical setting overseeing care management activities
  • Appropriate training and expertise in general psychiatry and or addiction disorders required.
  • Experience with governmental programs including Medicaid, Medicare, Long term care; additional experience in commercial/ MSO/ASO is a plus.
  • Administrative experience on a hospital committee, in a medical group or for an insurer preferred.
  • Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment Protocols required.
  • Knowledge and understanding of managed care principles, industry evolution, physician reimbursement, and human resource management required.

Licensure and/or Certification Required

  • Current unrestricted license to practice medicine in the State of New York.

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication