Behavioral Health Medical Director, Medicaid

Humana • Carapichaima, IN

4d • $223,800 - $313,100 • Remote

About The Position

The Behavioral Health Medical Director is responsible for behavioral health care strategy and/or operations. The Behavioral Health Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. Support Humana’s values by working collaboratively and effectively within a team-based environment. Apply medical training, clinical experience, and professional judgment to determine whether requested services, levels of care, or sites of service should be authorized. Ensure all determinations are made within a regulatory compliance framework and are supported by appropriate resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other applicable resources. Learn and apply Medicaid requirements, including the ability to operationalize this knowledge in daily work within the assigned cluster. Perform computer-based reviews of moderately complex to complex clinical scenarios, including review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and potential participation in care management activities. Review clinical scenarios arising from both outpatient and inpatient care settings. Conduct telephone discussions with external physicians to obtain additional clinical information or discuss determinations through the peer-to-peer review process. Use conflict resolution skills when needed during physician discussions, particularly in complex or sensitive determination conversations. Engage with contracted external physicians, physician groups, facilities, or community organizations to support regional market priorities. Demonstrate an understanding of Humana processes and support collaborative business relationships, value-based care initiatives, population health strategies, and disease or care management programs as applicable. Provide coverage and flex across the assigned cluster as needed, including support for vacations, weekends, and holidays.

Requirements

• Doctor of Medicine or Doctor of Osteopathy
• Board-certified in ABMS or ABPN recognized specialty of Psychiatry (Neurology not accepted)
• A current and unrestricted license through the Interstate Medical Licensure Compact in at least one jurisdiction and willing to obtain additional licenses when required
• No current sanction from Federal or State Governmental organizations, and able to pass onboarding requirements.
• 2+ years of project management experience
• At least five years of experience post-training providing clinical services
• Experience in utilization management review and case management in a health plan setting
• Excellent verbal and written communication skills with analytic and interpretative skills from prior experience focusing on quality, utilization, and/or case management
• Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual

Nice To Haves

• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting
• Experience with accreditation process (NCQA)
• Experience with CGX and MHK
• Has licensure through the Interstate Medical Licensure Compact (IMLC)
• Has a Indiana medical license
• Has experience with application of MCG and ASAM criteria

Responsibilities

• Responsible for behavioral health care strategy and/or operations.
• Apply medical training, clinical experience, and professional judgment to determine whether requested services, levels of care, or sites of service should be authorized.
• Ensure all determinations are made within a regulatory compliance framework and are supported by appropriate resources.
• Learn and apply Medicaid requirements, including the ability to operationalize this knowledge in daily work within the assigned cluster.
• Perform computer-based reviews of moderately complex to complex clinical scenarios, including review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and potential participation in care management activities.
• Review clinical scenarios arising from both outpatient and inpatient care settings.
• Conduct telephone discussions with external physicians to obtain additional clinical information or discuss determinations through the peer-to-peer review process.
• Use conflict resolution skills when needed during physician discussions, particularly in complex or sensitive determination conversations.
• Engage with contracted external physicians, physician groups, facilities, or community organizations to support regional market priorities.
• Demonstrate an understanding of Humana processes and support collaborative business relationships, value-based care initiatives, population health strategies, and disease or care management programs as applicable.
• Provide coverage and flex across the assigned cluster as needed, including support for vacations, weekends, and holidays.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree