Note: The job is a remote job and is open to candidates in USA. California Mental Health Services Authority is seeking a Quality Management Clinician to support their regional Drug Medi-Cal Organized Delivery System (DMC-ODS) administrative model. This role involves providing clinical leadership for quality management, utilization management, and care delivery oversight activities, while ensuring compliance with state and federal requirements.
Responsibilities
- Conduct clinical service authorization, reauthorization, and medical necessity reviews for delegated DMC-ODS functions, including residential and withdrawal management services, as applicable
- Apply ASAM criteria, DMC-ODS requirements, Medi-Cal medical necessity standards, and parity considerations to clinical review and utilization management activities
- Provide clinical consultation on access, screening, referral, care coordination, placement, transitions between levels of care, and residential step-down planning
- Develop and review clinical policies, procedures, practice guidelines, training expectations, and clinical workflow standards for delegated DMC-ODS functions
- Provide clinical leadership for provider onboarding, implementation support, and provider-facing operations related to access, screening, documentation, care coordination, and service delivery expectations
- Oversee clinical components of provider credentialing/recredentialing standards, including review of provider qualifications, scope of services, and clinical service capacity
- Lead clinical quality improvement activities, including QI Work Plan development, PIP coordination, clinical trend review, and development of clinically informed improvement strategies
- Review utilization, access, grievance, provider performance, and quality data to identify clinical risks, gaps in care, and opportunities for improvement
- Provide clinical input into provider monitoring, site reviews, chart reviews, corrective action plans, and follow-up related to clinical quality or service delivery concerns
- Provide training and technical assistance to counties, providers, and internal teams on DMC-ODS clinical requirements, ASAM criteria, medical necessity, documentation expectations, and care coordination standards
- Represent CalMHSA in clinical quality, utilization management, provider, county, EQRO, DHCS, and other stakeholder meetings, as assigned
- This position will have access to various applications that house confidential information related to consumer demographics and behavioral health; ensure that access is used responsibly, maintaining the integrity and security of systems while preventing accidental or malicious misuse
- Perform other duties as assigned, demonstrating flexibility and commitment to organizational success
Skills
- Master's degree in Social Work, Marriage and Family Therapy, Professional Clinical Counseling, Psychology, or related clinical field, required
- Current California Board of Behavioral Sciences (BBS) licensure or license eligibility required; acceptable credentials may include LMFT, LCSW, LPCC, AMFT, ACSW, APCC, or equivalent BBS-recognized status
- Minimum of five (5) years of experience in behavioral health, substance use disorder treatment, quality management, utilization management, clinical program oversight, or a closely related field, required
- Strong clinical knowledge of substance use disorder treatment, DMC-ODS services, ASAM criteria, medical necessity, care coordination, and transitions between levels of care
- Strong understanding of California county behavioral health plan operations, Medi-Cal managed care requirements, and DMC-ODS contract requirements
- Ability to conduct clinical review and apply regulatory, contractual, and clinical standards to authorization, quality, provider monitoring, and compliance activities
- Excellent written and verbal communication skills, including the ability to develop clear clinical guidance, training materials, reports, and policy/procedure documents
- Ability to work effectively with county leaders, providers, clinical staff, state partners, and internal cross-functional teams
- Strong facilitation, technical assistance, and provider engagement skills
- Ability to analyze clinical, quality, access, utilization, and performance data to identify trends and recommend improvement strategies
- Strong organizational skills and ability to manage multiple projects, deadlines, and stakeholder expectations
- Ability to exercise sound clinical judgment, maintain confidentiality, and communicate sensitive information professionally
- Demonstrate the ability to use a computer and applicable computer software effectively. Intermediate knowledge of Excel & Word, PowerPoint, Adobe, and Outlook required
- Demonstrate the ability to read, comprehend, and respond appropriately through written or verbal form; demonstrate tactfulness when communicating with internal staff, counties, providers, state partners, and other stakeholders
- Demonstrate the ability to effectively apply clinical judgment, regulatory requirements, and common sense to daily tasks; demonstrate the ability to work independently with limited supervision; demonstrate excellent analytical and critical thinking skills; demonstrate the ability to conduct research, ask appropriate probing questions, identify risks, and develop practical solutions
- Experience with DMC-ODS, including ASAM criteria, medical necessity, authorization processes, residential treatment, withdrawal management, care coordination, and Medi-Cal documentation requirements, strongly preferred
- Experience working within or directly with a County Behavioral Health Plan, particularly overseeing or supporting DMC-ODS functions, strongly preferred
- Experience with provider monitoring, credentialing/recredentialing, site reviews, chart reviews, quality improvement, EQRO, PIPs, or corrective action processes, preferred
- Experience with electronic health records, utilization management platforms, provider management systems, or data/reporting systems preferred
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