This part-time, contract physician role provides clinical oversight for behavioral health utilization review, with a focus on auditing determinations, reviewing medical necessity and level-of-care decisions, and coaching physician reviewers. The work centers on psychiatric utilization management and quality assurance for behavioral health cases, including handling escalations, grievances, and reviewer performance concerns. The clinician also supports training, client-facing discussions, and collaboration with operations, QA, and leadership teams.
Key Responsibilities
- Provide clinical oversight and subject matter expertise for behavioral health utilization review activities.
- Audit cases completed by newly onboarded and ongoing behavioral health physician reviewers and provide feedback, coaching, or retraining.
- Review quality misses, inappropriate determinations, and rationale issues, and provide timely clinical remediation.
- Support QA and operational teams with live case escalations involving behavioral health determinations and reviewer performance.
- Assist with reviewer training, documentation expectations, and quality management activities.
- Respond to client escalations and grievances, including root-cause review and remediation planning.
- Participate in client-facing calls, audits, and touch-base meetings as the behavioral health physician subject matter expert.
- Collaborate with leadership, QA, operations, and physician network teams to support consistent behavioral health utilization review.
Required
- MD or DO with board certification in Psychiatry.
- Active, unrestricted medical license.
- Prior utilization review experience in a health plan, independent review organization, managed care, or similar environment.
- Experience with ASAM Criteria and behavioral health medical necessity and level-of-care review.
- Working knowledge of behavioral health utilization management criteria and guidelines, including LOCUS/CALOCUS, MCG, and InterQual.
Preferred
- Child and Adolescent Psychiatry experience or certification.
Benefits & Perks
- Part-time contract role with an anticipated commitment of approximately five hours per month.
- Additional participation may be added by mutual agreement based on business or client needs.