Medical Director (Behavioral Health OhioRISE)
CVS Pharmacy - Columbus, OH
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Job DescriptionAetna, a CVS Health Company, a Fortune 4 company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a remote based (work at home). Candidate must reside in Ohio.As part of the bold vision to deliver the "Next Generation" of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among CMEs (Care Management Entities), MCOs, vendors, providers, PCSAs (Public Children Services Agencies) and Ohio Department of Medicaid to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.The Medical Director provides oversight for medical policy implementation, and participates in the development, implementation, and evaluation of clinical/medical programs.This is a full-time telework position, with travel up to 15% required for state meetings and visits to the New Albany office as needed. Expands Aetna's medical management programs to address member needs across the continuum of care. Supports the Medical Management staff ensuring timely and consistent responses to members and providers. Oversees utilization review/quality assurance, directing case management. Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities. Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. Responsible for predetermination reviews and reviews of claim determinations, providing clinical, coding, and reimbursement expertise. Expectation of collaboration with CMO. This includes supporting the execution of the CMOs clinical goals and being a subject matter expert resource to all OhioRISE departments (clinical and operational), CMEs, Providers, and state stakeholders. MDR will assist OhioRISE in achieving clinical contract deliverables and Aetna/CVS Health enterprise endeavors.Required Qualifications Active Ohio medical license without encumbrances. Persons willing to obtain will be considered. Residence in Ohio. 2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications Clinical experience with pediatric populations. Experience with multisystem involved youth. Experience with SUD (Substance Use Disorder) treatment. Experience with ASAM (American Society of Addiction Medicine) Criteria.Education M.D. or D.O., Board Certification required in a recognized specialty. Post-graduate direct patient care experience. Board Certification in Child & Adolescent Psychiatry preferred. Physicians board-certified in Pediatrics or Adolescent Medicine with significant behavioral health or Addiction Medicine experience/specialization will be considered.Business OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
Created: 2024-09-07