Senior Director Behavioral Health (Remote)

City/State

Norfolk, VA

Overview

Work Shift

First (Days) (United States of America)

#indeed, #LI-AB1 #Indeed #Talroo

Job Summary

This role is responsible for the strategic leadership of behavioral health and addiction recovery treatment services for the health plan. This includes program development, design, outcomes measurement, and evaluation of behavioral health programs for the Medicaid and Medicare lines of business for OHP and VPHP. Will also have oversight for Sentara Health Plan’s EAP product and program.

The primary role of this program is the oversight and operational execution of the Medicaid and Medicare Behavioral Health Utilization Management (UM) and Care Management (CM) Programs in meeting both the DMAS Medicaid requirements but also the Medicare MAPD, DSNP and CSNP requirements for the end-to-end BH UM and BHCM programs. This position is responsible for meeting all regulatory and accreditation requirements and in meeting clinical, quality, and Clinical Efficiency targets, DMAS PWP, clinical KPI and MLR targets.

The BH UM functions apply to members in need of inpatient and outpatient behavioral health needs requiring authorization and include precertification (prior auth) concurrent review, retrospective review, the application of evidenced based clinical criteria for decision making, adhering top all Medicaid and Medicare approval and denial processes inclusive of member and provider letters and meeting all turnaround time standards and ensuring continuity of care. The BH UM inpatient function applies to inpatient psych facilities and the outpatient function applies to crisis stabilization, Addiction Recovery (ARTS), Community Mental Health Related Services (CMHRS), justice program, Peer support programs, prisoner early release program and transition of care. This program is accountable to impact clinical KPI’s related to a reduction in the MLR

The BH CM functions follows the Medicaid and Medicare requirements for case management. The primary role of this program is the oversight and operational execution in meeting both the DMAS/CMS Medicaid/Medicare requirements and the NCQA Medicaid Health Plan Accreditation and the NCQA Medicaid LTSS Distinction. This position is responsible for meeting all regulatory and accreditation requirements and in meeting Clinical Efficiency, PWP targets as well as compliance with all benchmark requirements for reporting and measures tied to Care Management functions. The department is key to gaps in care management in meeting HEDIS measures

• Oversight and execution of the Health Plans Utilization Management Program and Case
Management Programs as defined above
• Performance Management oversight and accountability for both utilization and case
management reg and operational reporting, production metrics, clinical KPI’s and staff
performance and accountability; strong analytic component to role in driving results based on
data and trends
• Drives business operations and tactics in support of impacting the MLR, clinical KPI’s such as
admits and bed days/k, ALOS, medical director referral and denial rates, readmission rates, ER
rates and Clinical Efficiency measures/targets, Medicaid PWP measures, Cost of Care tactical
ideation and execution and the BH HEDIS rates
• Achieve new BH NCQA Accreditation
• Responsible for implementation of various new programs, initiatives and vendor projects and
the resultant success thereof
• Budget and staff management responsibilities to provide ROIs to support changes in staffing
complement or development of new programs
• Responsible for all UM and CM reg reporting validation is complete and timely and represents
results to DMAS/CMS and various audits conducted by DMAS, CMS, NCQA, QI and internal
audit
• Responsible for the success of the UM and CM components of the Medicaid NCQA
Accreditation and the Medicaid NCQA LTSS distinction
• Serve as thought leader to various department leaders, plan presidents, plan vice presidents
and various departments related to all requirements and communications for members and
providers related to the utilization management and care management programs

• Oversight and execution of the BH Component of the DMAS Care Management Model of Care
(Cardinal) includes adherence to all Health Risk Assessment, Interdisciplinary Care Plan, Mental
health Screenings timing and documentation requirements, in addition to the provision of care
management services using risk stratification to define the BH related subpopulations
• Contribute to the results of the Medic