Location: This position may work remotely anywhere in the United States of America.

Who we are

Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®.

We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement.

About the role

The Behavioral Health Medical Director serves as a key behavioral health clinical resource and strategic thought leader for Quantum Health. This position establishes protocols for behavioral health medical treatment inquiries, renders determinations on requests for services and treatment, and conducts daily reviews and case level conversations. The Behavioral Health Medical Director partners with internal and external stakeholders to enhance behavioral health program and service design and delivery, regulatory compliance, and member satisfaction.

What you’ll do

• Serves as a thought partner and clinical consultant to define the company’s strategy for Behavioral Health case management and utilization management services. Actively participates in implementing, maintaining, and refining innovative Behavioral Health support for members.
• Assists clinical operations leadership in planning and establishing goals and policies to improve quality and cost effectiveness of behavioral health care and service to members and clients based on internal data and external evidence-based studies and data.
• Provides medical expertise for the behavioral health utilization management and care coordination programs to ensure compliance with regulatory requirements.
• Establishes criteria and protocols for standard behavioral health medical treatment inquiries and renders determinations on requests for healthcare services and/or treatment.
• Performs utilization review and case management support for members with complex behavioral health needs
• Conducts daily review of complex behavioral health cases and conducts necessary case level conversations, including prior authorization and denial decisions for cases that do not meet established evidence-based criteria.
• Provides clear and concise documented medical review determinations and support on requested reviews within the established time frames
• Provides clinical consultations
• Identifies opportunities to implement best practices approaches and introduce innovations to provide improved outcomes
• Provides support over the phone, through messaging and video to support chronic disease management to internal Quantum Health clinicians
• Offers peer-to-peer discussions regarding determinations as necessary
• Serves as a medical liaison to physicians, hospitals and insurance carriers
• Provides determination on appeals for cases where they did not make the initial determination
• Utilizes data resources and tools that enable the company’s behavioral health teams to provide personalized care to members
• Evaluates and interprets data. Identifies areas for improvement with a focus on interventions to improve behavioral health outcomes.
• Conducts education sessions to provide Behavioral Health training/coaching and presents current market trends to clinical and non-clinical staff.
• Other duties as assigned

What you’ll bring

• Education: M.D. or D.O.
• Licenses: Active, unrestricted medical license; must be eligible for multistate licensure
• Board-certified in Psychiatry
• Minimum of 5 years clinical experience
• At least 2 years of experience conducting physician clinical reviews, preferably within a commercial health plan
• Proficiency with InterQual or MCG criteria and knowledge of healthcare delivery systems
• Demonstrated ability to interpret complex data and translate findings into actionable strategies
• Strong written and verbal communication skills; experience presenting to clinical and executive stakeholders
• Collaborative, team-oriented approach with a strategic and solution-focused mindset
• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
• A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us.

#LI-HW1 #LI-Remote

What’s in it for you

• Compensation: Competitive base and incentive compensation
• Coverage: Health, vision and dental featuring our best-in-class healthcare navigation services, along with life insurance, legal and identity protection, adoption assistance, EAP, Teladoc services and more.
• Retirement: 401(k) plan with up to 4% employer match and full vesting on day one.
• Balance: Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
• Development: Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid trainings and leadership development.
• Culture: Recognition as a Best Place to Work for 15+ years, dedication to diversity, philanthropy and sustainability, and people-first values that drive every decision.
• Environment: A modern workplace with a casual dress code, open floor plans, full-service dining, free snacks and drinks, complimentary 24/7 fitness center with group classes, outdoor walking paths, game room, notary and dry-cleaning services and more!

What you should know

• Internal Associates: Already a Healthcare Warrior? Apply internally through Jobvite.
• Process: Application > Phone Screen > Online Assessment(s) > Interview(s) > Offer > Background Check.
• Diversity, Equity and Inclusion: Quantum Health welcomes everyone. We value our diverse team and suppliers, we’re committed to empowering our ERGs, and we’re proud to be an click here to submit a recruitment accommodation request.
  
  
  

  Recruiting Scams: Unfortunately, scams targeting job seekers are common. To protect our candidates, we want to remind you that authorized representatives of Quantum Health will only contact you from an email address ending in @quantum-health.com. Quantum Health will never ask for personally identifiable information such as Date of Birth (DOB), Social Security Number (SSN), banking/direct/tax details, etc. via email or any other non-secure system, nor will we instruct you to make any purchases related to your employment. If you believe you’ve encountered a recruiting scam, report it to the .