Company Description

Job Description

• Perform physician-level utilization management reviews for behavioral health services across levels of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient services
• Render medical necessity determinations using company-approved, evidence-based criteria (e.g., InterQual®, MCG®, or plan-specific guidelines)
• Review escalated, complex, and reconsideration cases, including first- and second-level appeals, as requested
• Ensure determinations are timely, clinically appropriate, and consistently applied across commercial product lines

• Conduct peer-to-peer consultations with treating psychiatrists and other behavioral health providers
• Communicate clear, clinically sound rationales for utilization management decisions
• Support resolution of provider disputes related to medical necessity or level-of-care determinations

• Apply utilization management criteria and processes in compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA)
• Ensure non-quantitative treatment limitations (NQTLs), including prior authorization requirements, review standards, and clinical criteria application, are comparable to and no more stringent than those applied to medical/surgical benefits
• Support parity analyses, documentation, and regulatory inquiries as requested
• Provide clinical input on parity-related policies, utilization management practices, and corrective action plans

• Perform utilization management activities in alignment with NCQA Health Plan Accreditation standards
• Support readiness for NCQA surveys, audits, and corrective actions related to behavioral health utilization management
• Assist with development, review, or refinement of utilization management policies and procedures to maintain accreditation compliance

• Serve as a consultative clinical resource to behavioral health utilization management nurses, care managers, and operational leaders
• Provide recommendations to improve utilization management consistency, quality, efficiency, and provider experience
• Participate in scheduled or ad hoc clinical, quality, or utilization review meetings as requested

• Timely completion and documentation of assigned utilization management reviews and determinations
• Written clinical rationales supporting authorization, denial, or modification decisions
• Documentation supporting MHPAEA compliance and NCQA standards, as applicable
• Verbal or written recommendations related to utilization management process or policy improvements

Qualifications

• MD or DO with board certification or board eligibility in Psychiatry
• Active, unrestricted Illinois medical license (required)
• Minimum of 3 years of post-residency psychiatric practice
• Prior experience in utilization management, managed care, or medical director roles

• Experience supporting commercial health plans
• Familiarity with behavioral health parity and accreditation standards (e.g., NCQA)
• Strong peer-to-peer communication and clinical documentation skills

• 1099 independent contractor engagement
• Part-time, flexible schedule (approximately 6 hours per week)
• No minimum hours guaranteed
• Must maintain sufficient availability to meet regulatory and turnaround time requirements

Additional Information

• Accountability: transparency, reliability, and integrity
• Always Growing, Always Learning: continuous improvement
• Collaborative Innovation: solve problems creatively
• Every Voice Matters: value diverse perspectives
• Empathy in Action: build stronger connections

• Work from Home: Guidehealth is a fully remote company
• Comprehensive Medical, Dental, and Vision plans (for eligible employees)
• 401(k) plan with 3% employer match to a 6% contribution (for eligible employees)
• Life and Disability insurance; voluntary life options
• Employee Assistance Program (EAP)
• Paid time off plans
• Paid parental leave
• Learning and development resources