Provide physician-level oversight and clinical expertise for behavioral health utilization management activities.
Review behavioral health cases to evaluate medical necessity, appropriateness of care, level of care, and treatment plans.
Conduct clinical reviews involving behavioral health and substance use disorder services as appropriate.
Provide consultation to clinical staff regarding complex or difficult behavioral health cases.
Participate in clinical rounds, case discussions, and other physician review activities as needed.
Review and evaluate cases requiring physician-level determination or escalation.
Apply appropriate clinical criteria, policies, and evidence-based standards when making utilization management decisions.
Provide clinical input regarding appeals, reconsiderations, and other utilization-related reviews.
Help identify trends and opportunities related to behavioral health utilization, quality, access, and patient outcomes.
Review available clinical and operational data to identify opportunities for improvement.
Provide behavioral health expertise to support clinical programs, quality initiatives, and care management strategies.
Collaborate with internal clinical and operational teams to promote appropriate coordination between behavioral and physical healthcare.
Work with network providers and other healthcare stakeholders when physician-level behavioral health expertise is needed.
Support initiatives designed to improve quality of care, patient experience, outcomes, and appropriate utilization of healthcare resources.
Participate in quality improvement, accreditation, regulatory, and clinical governance activities as needed.
Provide coverage and additional clinical support during physician absences or periods of increased case volume.
MD or DO degree from an accredited medical school.
Current unrestricted Pennsylvania medical license.
Current Board Certification in an appropriate behavioral health specialty, such as Psychiatry.
At least 5 years of clinical experience following residency, with experience treating behavioral health conditions in inpatient and/or outpatient settings.
Strong clinical background in mental health and/or substance use disorders.
Experience evaluating medical necessity, level of care, treatment appropriateness, or utilization management.
Strong clinical judgment and ability to evaluate complex cases independently.
Ability to interpret clinical information and apply established medical necessity criteria and policies.
Strong written and verbal communication skills.
Ability to explain complex clinical information clearly to physicians, clinicians, and non-clinical stakeholders.
Ability to work independently while remaining highly collaborative with a broader clinical team.
Strong organizational skills and ability to manage multiple cases or priorities efficiently.
Comfortable working within electronic medical records, clinical systems, and other technology platforms.
Current professional liability coverage or eligibility for coverage.
Ability to meet all applicable credentialing and regulatory requirements.
SGC is a Certified Small Diverse Business for the Commonwealth of PA serving Harrisburg, Hershey, Mechanicsburg, Carlisle, Lancaster, Allentown, State College, York, Sunbury, Philadelphia & Baltimore.
