Behavioral Health Child and Adolescent Psychiatric Medical Reviewer

This position is PRN (per diem).

The Behavioral Health (BH) Child and Adolescent Psychiatric Medical Reviewer will serve as a member of the Medical Affairs and Utilization Management team within health plan. The Medical Reviewer will be responsible for conducting medical necessity reviews for Behavioral Health service requests which require prior authorization for the HSCSN enrollment population which includes children, adolescents, and adults. The scope of reviews includes requests for community-based behavioral health services, general outpatient behavioral health services, inpatient acute psychiatric services, subacute residential levels of care, and the continuum of residential services. Additional services subject to Psychiatric Medical Reviewer coverage include contracted services such as Applied Behavioral Analysis (ABA) therapy, Intensive in-home services and the full range of ASAM levels of substance use disorder services.

This position is required to support HSCSN contractual and regulatory required activities effective HSCSN FY2025. The Behavioral Health Child and Adolescent Medical Reviewer/Peer Advisor will serve as a member of the Medical Affairs team and report to the Chief Psychiatric Medical Officer. They will be responsible for utilization review activities for Behavioral Health service requests which require prior authorization that are contractually required to be reviewed by a Board Certified/Board Eligible (BCBE) licensed physician when 1st Level Utilization Management Reviewers are unable to make a medical necessity determination for a requested service. The Behavioral Health Child and Adolescent Medical Reviewer/Peer Advisor needs to be well versed in mental health diagnoses, standards of care, and clinical practice guidelines. Due to the integrated nature of the HSCSN population, Child and Adolescent medical reviewer/Peer Advisor must also have good general working knowledge of general medical conditions which impact HSCSN enrollees PH and BH conditions. The Behavioral Health Child and Adolescent Medical Reviewer/Peer Advisor will also provide guidance and oversight to the CM and UM staff related to the management of the complex system of care needs of the HSCSN enrollee population. Individuals in this position will also monitor and provide guidance on quality-of-care concerns which arise consistent with standard HSCSN complex population management processes. The individual in this position can review all levels of BH services within their scope of practice except for Psychological Testing and Neuropsychological testing requests for service, which require review by a PhD or PsyD level Psychologist.

Minimum Education

Medical Doctor (M.D.) Completed advanced degree in medicine (MD or DO) (Required)

Minimum Work Experience

5 years 5 years of clinical experience (Required)

3 years Managed Care organization background (Required)

Required Licenses and Certifications

Physician Licensed to practice medicine in the District of Columbia Upon Hire (Required) Board Certified in Psychiatry and Neurology Upon Hire (Required) Board Eligible or Board Certified in Child and Adolescent Psychiatry Upon Hire (Required)

Required Skills/Knowledge

Comprehensive understanding of the standards of care for the population of individuals with mental health disorders, substance use disorders, neurodevelopmental disorders such as Autism Spectrum Disorder, Intellectual/Developmental Disabilities

Comprehensive understanding of the standards of care for the population of individuals with co-occurring complex physical health and behavioral health conditions

Comprehensive understanding of Applied Behavior Analysis (ABA) Therapy and other community practice standards and evidence-based modalities for individuals with neurodevelopmental disorders

Comprehensive understanding of the behavioral health system of care and general evidence-based treatments, including pharmacologic management of BH conditions

Job Functions

Review and promote adherence to utilization, quality, and care management polices related to community-based behavioral health service requests within the array of services identified in the CASSIP contract and as specified within the scope of the HSCSN covered benefitsa. Provide secondary review for requests b. Conduct peer to peer calls to review cases/understand treatment plansc. Work with treatment teams, including direct providers, primary care physicians (PCPs), specialists and DCPS/school, to adjust hours as appropriate to the member and their progressReview and promote adherence to utilization, quality, and care management policies related to the substance use disorder continuum service requests within the array of services identified in the CASSIP contract and as specified within the scope of the HSCSN covered benefitsa. Provide secondary review for requests b. Conduct peer to peer calls to review cases/understand treatment plansc. Work with treatment teams, including direct providers, primary care physicians (PCPs), specialists and DCPS/school, to adjust hours as appropriate to the member and their progressReview and promote adherence to utilization, quality, and care management policies related to Applied Behavior Analysis (ABA) service requestsa. Provide secondary review for requestsb. Conduct peer to peer calls to review cases/understand treatment plansc. Work with treatment teams, including direct providers, primary care physicians (PCPs), specialists and DCPS/school, to adjust hours as appropriate to the member and their progressReview and promote adherence to utilization, quality, and care management polices related to additional behavioral health service requests indentified as covered benefits for HSCSN a. Provide secondary review for requests which require prior authorizationb. Conduct peer to peer calls when indicatedc. Collaborate with treatment teams, including BH providers, primary care clinicians, specialists, DCPS/school, as appropriate to the enrollee and thier progress

Participate in meetings related to utilization management as indicated.

Provide case consultations when indicated (within HSCSN)

a. Assist Care Managers (CMs) with education about varying diagnoses, community resources, HSCSN resources, HSCSN policy and procedures regarding the services I work with.

b. Participate as a team member to review clinical picture, needs, and next steps for high-risk/highly complex enrollees.

c. Provide consultation as needed for CM staff who support Early Intervention services.

Provide Continuing Education and training to CM and UM staff when indicated.

Participate in provider education forums as indicated.

Provide input into the development and/or revision of policies as it relates to enrollees with behavioral health and substance use disorder conditions.

Complete medical necessity reviews as follows:

a. 2nd Level Reviews for BH services

b. Reconsiderations and Peer to Peers for BH services, substance use disorder conditions, specialized BH services within the HSCSN covered benefits.

c. Review documents submitted for appeals of adverse benefit determination decisions when applicable.

DC RESIDENTS ENCOURAGED TO APPLY