C.I.H. provides access to Medicaid and state-funded benefits, providers and supports for more than 850,000 individuals with complex needs. Using a community-based model of care management, C.I.H seeks to improve the health and wellness of its members by collaborating with local providers and stakeholders. Recognized for operational excellence, innovative solutions and superior outcomes for members, as well as accuracy and speed of payments to providers and cost-effective funds management, C.I.H is a leading managed care organization proud to serve North Carolina’s most vulnerable citizens.
Primary Purpose of Position:
The Medical Director has primary responsibilities for promoting high level quality and clinical integrity of the utilization management activities for the special populations served by C.I.H. These activities include promoting access to best practice treatment modalities for the membership, oversight of a high quality provider network and skilled C.I.H. based clinical team. The Medical Director will provide medical leadership for C.I.H. by working with the Chief Medical Officer, the Medical Department and Quality and Clinical Leadership at the Vice President level at a minimum to provide medical and quality oversight for C.I.H. clinical operations. The Medical Director shall be responsible for the proper authorization and review of covered services to enrollees, ensuring that employees conducting authorization reviews operate within the scope of their clinical expertise, and that services provided are both medically necessary and provided by qualified providers. C.I.H. serves a 20-county region of North Carolina which spans the I-85 corridor from Virginia to South Carolina. The Medical Director will serve in geographic regions within the 20-county area to be determined. Particular focus and planning is directed within the specified region and the director will ensure alignment with the overall C.I.H. strategic plan.
The Director reports to the Chief Medical Officer (CMO) and will assist in identifying and developing emerging/innovative strategies for improving and expanding clinical lines of business for the company including activities such as strategic planning, managing strategic clinical and other business relationships, partnering in the development of clinical analytics, and participating in quality improvement oversight and activities.
Responsibilities and Duties:
The Medical Director is responsible for (though not limited to):
- Collaborates with the CMO and Medical Department in the ongoing operations at the regional level including the local community stakeholders to include the C.I.H. Community Operations team and Member Engagement team
- Works within the Medical Department on the ongoing development and implementation of the C.I.H. Clinical Design Plan
- Innovates, collaborates, and tracks regional clinical initiatives and strategizes with the CMO on impacts of local initiatives on the overall strategic plan for the organization
- Participates in designated C.I.H. Corporate initiatives related to meeting the needs of special populations
- Participation in designated Corporate Committees as assigned (Examples of committees include the Clinical Management Team Meeting, Network Operations Cross Functional Team meeting, Regional Operations Team Meeting, and Continuous Quality Improvement Committees)
- Participates in complex clinical case reviews and treatment authorizations/reconsiderations/daily review of cases
- Conducts reviews for Medical Necessity at the Peer Advisor level which will include reconsiderations and appeals for Mental Health, Substance Abuse/Use and Intellectual and Developmental Disabilities lines of business inclusive of maintenance of minimum standards of documentation
- Provides coverage for the Medical Department as indicated as part of the Medical Team
- Participates in state, local and regionally based committees as indicated (such as the Crisis System Committee and Interdisciplinary Team Meetings for CCNC)
- Collaborates with appropriate C.I.H. staff to support and advance quality improvement activities
- Collaborates within the Medical Department and provides oversight of application of Medical Necessity criteria for service eligibility (type of service, amount, and duration)
- Participates in the ongoing development of medical necessity criteria
- Participates in and conducts trainings for both C.I.H. internal team members including rotation in Grand Rounds schedule, operations specific training events and provider specific/external stakeholder trainings and educational events
- Maintains fidelity and internal consistency of process of reviews for requests for service and oversight for approvals and denials
- Participates in the development of clinical practice guidelines that reflect evidence based and consensus based practices that are focused on achieving outcomes of self-determination, independence and recovery
- Promotes consistent application of UM procedures for each level of care that are consistent with practice guidelines
- Provides oversight and input into ongoing Utilization Management Plan and implementation that reflects a utilization management program which monitors services authorized and used by consumers to ensure that members receive the care indicated and consistent with practice guidelines
- Ensures consistency and integrity through formal procedures and clinical protocols that are developed in accordance with best practices, within state and federal requirements and medical necessity
- Represents C.I.H. with external customers such as physician and medical groups, advocacy groups and stakeholders at the state and local level in order to establish and maintain collaborative relationships and participate in designated committees as indicated
- Participates in/provides input into credentialing/qualifying providers to ensure that services are provided by qualified providers and has oversight for monitoring of providers
- May provide supervision of other medical staff members
- Conducts completion of review of critical incidents as part of overall Quality oversight consistent with internal policy and procedures
Knowledge, Skills and Abilities:
This position requires a high degree of attention to detail, ability to be flexible and responsive to rapidly changing conditions, ability to exercise a high degree of schedule management, and ability to triage and prioritize responsibilities and demands.
Experience with public community mental health services and consumers with serious mental illness, co-occurring mental illness and substance abuse, children with mental health conditions, as well as experience with developmental disabilities populations is very important.
The employee must have a wide knowledge of medical, pharmacological, and service -related supports needs of these populations in order to make decisions about need for care as well as to provide consultation and advice to other community physicians.
Employee must have a high degree of clinical skill set as it relates to Psychiatric, Medical, Substance Use and Intellectual/Developmental Disabilities as well as an ability to manage complex psychiatric and medical conditions.
The employee must be able to work collaboratively and effectively with both internal and external customers in order to develop processes, protocols, analyze data, and solve problems.
This is a high profile leadership position and it is important for the employee to be able to establish positive relationships with both the medical community and other key stakeholders.
The employee must be self-directed, able to organize and prioritize work, obtain and access needed information, interpret complex written materials, and be able to discriminate between essential and non-essential tasks.
Required Training and Education:
Completion of Medical school and completion of a residency in Psychiatry is required. The physician must be Board Certified or Board Eligible for Psychiatry certification by the American Board of Psychiatry and Neurology. The physician must be licensed to practice in at least one state and obtain an unrestricted North Carolina license to practice medicine. Managed care and community mental health experience, or experience with Medicaid and other publicly served population required. At least two years of post-graduate clinical experience is also required.
This is an office-based position at headquarters in Charlotte, NC. Occasional travel may be required within the State of North Carolina. Carolina Cardinal Innovations reserves the right to call upon this employee during non-business hours as needed to meet the demands of the position.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.