Medical Director-Psychiatry

Accountabilities: In this role, you will guide clinical utilization management activities, make informed medical necessity determinations, and collaborate with internal and external stakeholders to support appropriate, high-quality care. Your responsibilities will include: Medical Necessity Reviews: Conduct comprehensive prospective, concurrent, and retrospective reviews across a broad range of healthcare services, applying clinical expertise, medical policies, and evidence-based guidelines. Prior Authorization Management: Perform thorough prior authorization reviews to ensure decisions align with clinical criteria, regulatory requirements, and contractual agreements. Peer-to-Peer Discussions: Lead discussions with requesting practitioners, communicate clinical rationales clearly, encourage constructive dialogue, and identify alternative solutions when appropriate. Clinical Determinations: Issue medical necessity denials when warranted, providing thorough and well-documented rationales in accordance with applicable regulations and appeal processes. Cross-Functional Collaboration: Work closely with Nurse Practitioners, Care Coordinators, and Operations teams to strengthen utilization management workflows and improve member outcomes. Medical Policy Development: Contribute to the creation, review, and revision of medical policies, clinical guidelines, and utilization management protocols. Quality Improvement: Participate in quality improvement initiatives, audits, and clinical committee meetings as required. Documentation and Compliance: Maintain accurate and comprehensive records of review activities, clinical decisions, and peer-to-peer interactions. Clinical and Regulatory Updates: Stay informed about medical literature, healthcare developments, regulatory changes, and industry best practices in utilization management. Member-Centered Care: Promote a member-focused approach while balancing clinical effectiveness, appropriate resource utilization, and cost considerations. Continuous Improvement: Adapt to evolving organizational needs, take a proactive approach to problem-solving, and contribute hands-on to the development of clinical operations. Requirements The ideal candidate will be an experienced, board-certified psychiatrist with a strong background in clinical practice and healthcare utilization management. You should demonstrate sound medical judgment, excellent communication skills, and the ability to make complex clinical decisions while managing a high volume of cases in a remote environment. Required qualifications include: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school. Board certification in Psychiatry. Active and unrestricted medical license in at least one U.S. state, with the ability to obtain additional state licenses as needed. Support for additional licensure will be provided. Minimum of 5 years of clinical practice experience. Minimum of 2–3 years of experience in utilization management, medical review, or prior authorization within an insurance or managed care organization. Demonstrated experience conducting peer-to-peer discussions with external practitioners. Strong understanding of medical necessity criteria, evidence-based medicine, and healthcare utilization management principles. Excellent analytical and critical-thinking skills, with the ability to assess complex clinical information and make sound medical decisions. Exceptional written and verbal communication skills, including the ability to explain complex medical determinations clearly and empathetically. Proficiency with electronic health record (EHR) systems and utilization management software. Strong organizational skills and the ability to manage a high volume of cases independently in a remote work environment. Self-motivated, adaptable, and comfortable working in a fast-paced, evolving organization. A proactive, hands-on approach and genuine enthusiasm for contributing to an innovative healthcare environment. Benefits Salary: Annual compensation ranging from $260,000 to $280,000. Medical Coverage: 100% employer-paid medical premiums for employees and 50% coverage for dependents under the base plan. Healthcare Access: $0 copays and $0 deductibles upon completion of the Baseline Visit. Preventive and Primary Care: Integrated preventive and primary healthcare services. Mental Health Support: Access to mental health resources. Care Navigation: One-on-one care navigation support. Chronic Condition Programs: Dedicated programs supporting diabetes, weight management, and hypertension. Family Health Support: Maternity and family planning resources. Telehealth: Access to 24/7/365 telehealth services. Pharmacy Benefits: Prescription medication coverage. Dental and Vision: Comprehensive dental and vision insurance. Life and Disability Coverage: Employer-provided life and disability insurance, with additional supplemental coverage options. Flexible Spending Accounts: Access to flexible spending account programs. Work Arrangement: Remote and in-person work options, with this position offered remotely. Paid Time Off: Generous PTO policy and 11 paid company holidays annually. Retirement: 401(k) plan for full-time employees. Parental Leave: Up to 8–12 weeks of paid parental leave, depending on role eligibility. Travel: No travel required.