Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

 

The Behavioral Health (BH) Medical Director provides clinical leadership and oversight across Capital’s behavioral health operations, including Utilization Management (UM), Care Management (CM), and clinical rounds. This role is responsible for conducting and overseeing medical necessity reviews, benefit determinations, and appeals, while ensuring adherence to evidence-based criteria and regulatory standards. The Medical Director collaborates with internal teams, external partners, and network providers to drive quality, improve member outcomes, and support organizational performance in HEDIS, STAR, and CAHPS measures. In addition, the position analyzes data to identify trends, informs policy and program development, and contributes to strategic initiatives that advance the Triple Aim of improving health, enhancing the member experience, and reducing medical costs. The Medical Director also plays a key role in supporting accreditation and regulatory compliance, actively participating in committees and quality improvement activities.

• Actively participates in and supports Capital’s BH clinical operations and activities, including Utilization Management (UM), Care Management (CM) and clinical rounds.
• Participates in BH Utilization Management activities, including medical necessity reviews, benefit determinations, clinical rounds, and appeals and grievances determinations. Reviews data to identify trends relating to these activities and provides feedback on medical necessity criteria and/or medical policies underlying BH utilization management decisions and subsequent appeals.
• Participates in and provides consultation and clinical oversight of BH Care Management activities, including complex case reviews and clinical rounds.
• Collaborates cross-departmentally (internally) and with key external stakeholders, including Capital’s network providers, to drive Triple Aim outcomes. Provides BH expertise to inform clinical programs and services that drive quality and HEDIS, STAR, and CAHPS improvement.
• Reviews and analyzes data to drive that transformation in improving member health, experience of care, and medical costs.
• Supports organizational accreditation efforts and regulatory review processes, including participation in key committees and quality improvement activities Performs activities in compliance with all applicable regulatory entities including NCQA, CMS, PID, and DOH, among others.
• Performs other related duties and assignments as requested and directed.

Skills

• Superior cross-functional collaboration.
• Demonstrated ability to drive results to completion while managing multiple projects and priorities competing for resources.
• Ability to complement leadership and other team members in their responsibilities and roles.
• PC literacy and ability to perform electronic research and respond to electronic requests.
• Team oriented attitude with the ability to work and interact with all levels both within and outside of CBC.
• Ability to effectively multi-task under pressure, meet deadlines, and deliver high quality work.
• Ability to move from broad strategic perspective to tactical implementation and translate thoughts into actionable plans to drive performance.
• Demonstrated excellent public speaking and written communication skills; experience in creating and presenting oral and written proposals and presentations; ability to convey complex or technical information in a manner that others can understand.
• Demonstrated organizational and time management skills.
• Self-motivated and works independently; highly accountable.
• Proven problem solving skills; the ability to systematically analyze problems, draw relevant conclusions, and devise appropriate courses of action.

Knowledge

• Knowledge of current and emerging BH trends, including physical and behavioral health integration models, population health, and alternative payment models.
• Knowledge of and prior involvement with complex and unique issues within the health care industry.
• Knowledge of health plan regulatory requirements, including CMS, NCQA, and the DOH.

Experience

• A minimum of five years of clinical experience, post residency, including both inpatient and outpatient care.
• A minimum of 8 years of experience in health care with an emphasis on analysis and process optimization.
• Managed Care Organization and/or health insurance plan experience preferred

Education, Certification, and Licenses

• MD or DO Degree, as well as appropriate Board Certification.
• Current unrestricted license in Pennsylvania as an MD or DO.
• Currently covered by, or eligible to be covered by, medical liability insurance.
• Current valid Pennsylvania drivers’ license.

Physical Demands

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must occasionally lift and/or move up to 5 pounds.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.