Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the health care equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs and a dedicated care team. For more information on Zing Health, visit www.myzinghealth.com.
Under the direction of the Chief Medical Officer, the Behavioral Health Medical Director provides medical oversight and expertise in the clinical appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. Facilitates conformance to Medicare, NCQA and other regulatory requirements. Reviews referred quality of care issues, focused reviews and recommends corrective actions where appropriate. Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.
Evaluates authorization requests in support of nurse reviewers; reviews
cases requiring concurrent review and manages the denial process utilizing CMS
clinical policies, InterQual, Milliman or other identified Evidence based
Medical Policies. Monitors service delivery to our members through the continuum
from outpatient services, acute and sub-acute hospital care, skilled nursing
facilities to home care to ensure quality, cost-efficiency, and continuity of
care. Ensures medical decisions are rendered by qualified medical personnel,
not influenced by fiscal or administrative management considerations, and that
the care provided meets the standards for acceptable medical care. Ensures that
medical protocols and rules of conduct for plan medical personnel are followed.
Monitors practitioner practice patterns and recommends corrective actions if
member of the Health Services Management team, the Behavioral Medical Director
is responsible for assisting in the development, implementation and review of
clinical protocols, performance objectives, productivity benchmarks. Also, the
position serves as coach/mentor/trainer to staff clinicians and other staff,
giving guidance on best practices, reviewing the delivery of medical services,
and identifying operational issues which may impact Member outcomes or staff
performance. The Behavioral Medical Director will assist in examining clinical
reporting, predictive analytics, and guidelines to identify members for
specific case management and/or disease management interventions by utilizing
established screening criteria. They
will conduct admission review, post-discharge, and discharge planning with the health
plan clinical staff. The Behavioral Medical
Director will be a key participant in integrated case management rounds and
actively seek additional resources or expertise as needed to assist the member
to achieve their best personal health care goals.
Able to utilizes IT and data analysis tools to report on, monitor
outcomes, and make suggestions to improve Utilization Management processes and
outcomes. Actively participates in regulatory, professional and community
Experience demonstrating strong management and communication skills,
consensus building and collaborative ability, and financial acumen.
ESSENTIAL POSITION RESPONSIBILITES
- Participates as member of the Health Services management team to develop and implement clinical programs to improve member outcomes.
- Utilization Review
- Case Management Rounds
- Integrated Care Team Rounds for C-SNP members
- Development of Integrated Care Plan for members
- Integrated Care Rounds
- Active Participation with training
- Maintain documentation compliant with Health Plan and CMS policies and procedures
- Meet or exceed all Plan Turn around times for assigned tasks
- Perform other related duties and/or projects as assigned by the CMO
- MD Board Certified in Psychiatry with an active and unrestricted Medical license in the United States
- Minimum 5 years of experience in leading teams and working with colleagues to identify and achieve structured goals.
- Minimum 10 years of established clinical experience and current clinical knowledge in Behavioral Health.
- 2+ years HMO/Managed Care experience preferred
- Possess data analysis and interpretation skills with prior experience working with teams focusing on quality management, utilization management, discharge planning and/or case management.
- Proven competency with Microsoft Office, Word, PowerPoint, Excel, Outlook
- Minimum 5 years’ experience in the managed care industry including Medicare, Medicare Advantage including experience in Utilization/Quality Program management. HMO/Managed Care experience.
- Knowledge of applicable state, federal and third-party regulations
- Experience in Peer Review, medical policy/procedure development, provider contracting experience.
- Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, medical coding and evidence-based guidelines.