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Assistant Medical Director – Behavioral Health Focus
Premera Blue Cross. Perform clinical review of pre-service, post-service, and concurrent behavioral health services .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review processes for behavioral health services, including medical necessity assessments and case consultations. Holds a valid medical license and board certification in psychiatry, with extensive experience in health plan settings.
Highest-signal resume keywords
Licensed Physician (MD or DO)Board Certification in PsychiatryClinical Review Experience in Health Plan SettingFamiliarity with MCG or InterQualExperience with CPT, ICD, and HCPCS Code Sets
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical ReviewMedical Necessity AssessmentBehavioral Health Services ReviewCase ConsultationInter-Rater Reliability EvaluationsClinical Criteria SetsCPT CodingICD CodingHCPCS CodingResource-Based Relative Value Scale (RBRVS)
Soft Skills
Collaboration with Clinical StaffCommunication with External PhysiciansSupport for Member Appeals
Certifications & Qualifications
Board Certification in PsychiatryWashington MD or Alaska DO State Licensure
Industry Keywords
Behavioral HealthMedical Review CriteriaPeer-to-Peer DiscussionsClinical PathwaysContinuing Education
About the role
Key responsibilities & impact- Perform clinical review of pre-service, post-service, and concurrent behavioral health services
- Review outpatient and facility-based behavioral health cases
- Consult with clinical staff on specific case reviews
- Make final coverage decisions based on medical necessity, investigational status, contractual exclusions, or network structure
- Support peer-to-peer discussions with external physicians and providers regarding denial determinations
- Collect additional clinical history relevant to case determinations
- Consult with nursing and other clinical staff to assess and explore care options for members
- Participate in development, annual review, and approval of company medical review criteria as a Premera Medical Policy Committee member
- Participate in Inter-Rater Reliability evaluations
- Respond to consultation requests from Premera Blue Cross and contracted practitioners and facilities
- Support member and provider appeals and conduct secondary reviews as needed
- Fulfill professional continuing education requirements and participate in ongoing education and training
Requirements
What you’ll need- Licensed Physician with an MD or DO degree (Required)
- Unrestricted Washington MD or Alaska DO state licensure, or ability to obtain within 90 days
- Current board certification in psychiatry from the American Board of Psychiatry and Neurology
- Five (5) years of clinical experience in psychiatry (Required)
- Previous experience performing medical necessity and clinical reviews in a health plan setting (Preferred)
- Familiarity or experience with clinical criteria sets and clinical pathways, such as MCG (Milliman Care Guidelines) or InterQual (Preferred)
- Familiarity or experience with CPT, ICD, and HCPCS code sets and resource-based relative value scale (RBRVS) pricing concepts (Preferred)
- Part-time availability of 20 hours per week
Benefits
Comp & perks- Medical, vision, and dental coverage with low employee premiums
- Voluntary benefit offerings, including pet insurance
- Life and disability insurance
- Retirement programs, including a 401K employer match and a pension plan vested after 3 years of service
- Wellness incentives, including mental well-being resources, counseling services, stress management programs, and mindfulness programs
- Generous paid time off
- Tuition assistance for undergraduate and graduate degrees
- Employee recognition program
- Flexibility for hybrid employees with access to on-site resources, networking opportunities, and team engagement
- Commuter perks
- Free convenient on-site parking
- Subsidized on-campus cafes
- On-site health and wellness activities
- Fitness and well-being center with in-person and virtual workouts and nutritional counseling
- Shuffleboard and ping pong on campus