Behavioral Health Medical Director

Humana•Louisiana, MO

3d•$223,800 - $313,100•Remote

About The Position

The Behavioral Health Medical Director is responsible for behavioral health care strategy and/or operations. The role addresses moderately complex to complex issues requiring in-depth evaluation of multiple factors and may involve developing procedures, processes, productivity targets, and new delivery models. The Medical Director maintains efficient operations while supporting quality-of-care and financial goals and provides information for pricing guidelines based on utilization patterns and client demographics. The role uses medical background, experience, and judgment to determine whether requested services, levels of care, and sites of service should be authorized. Decisions and daily work are guided by regulatory requirements and may draw on national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other expertise. The Medical Director learns Medicare, Medicare Advantage, and/or Medicaid requirements and applies them in daily work. The position may involve speaking with contracted external physicians, physician groups, facilities, and community groups to support regional market priorities. These interactions may focus on Humana processes, collaborative business relationships, value-based care, population health, or disease and care management. The role supports Humana values and its Bold Goal mission. This is a remote position, with occasional travel to Humana offices for training or meetings. Employees working from home or a hybrid home/office arrangement must have internet service with at least 25 Mbps download and 10 Mbps upload speeds and work from a dedicated space that protects member PHI and HIPAA information. The position is scheduled for 40 hours per week and is eligible for a bonus incentive plan.

Requirements

MD or DO degree.
At least 5 years of direct clinical patient care experience after residency or fellowship.
Current and ongoing Board Certification in an approved ABMS Medical or ABPN specialty.
Current and unrestricted license in at least one jurisdiction, and willingness to obtain additional licensure if required.
No current sanction from Federal or State Governmental organizations and ability to pass credentialing requirements.
Excellent verbal and written communication skills.
Evidence of analytical and interpretation skills.
Prior experience participating in teams focused on quality management, utilization management, case management, discharge planning, and/or home health or post-acute services such as inpatient rehabilitation.

Nice To Haves

Clinical experience in an inpatient environment and/or experience related to care of a Medicare or Medicaid population.
Knowledge of managed care, including Medicare Advantage, Managed Medicaid, Commercial products, medical management organizations, hospitals or Integrated Delivery Systems, health insurance, other healthcare providers, or clinical group practice management.
Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance.
Experience with national guidelines such as MCG® or InterQual.
Specialty in Psychiatry, Internal Medicine, Family Practice, Geriatrics, Hospitalist medicine, or Emergency Medicine.
Advanced degree such as an MBA, MHA, or MPH.
Exposure to Public Health, Population Health, analytics, and use of business metrics.
Experience working with case managers or care managers on complex case management, including familiarity with social determinants of health.
Curiosity to learn, flexibility to adapt, and courage to innovate.

Responsibilities

Support behavioral health care strategy and/or operations.
Develop procedures, processes, productivity targets, and new delivery models as needed.
Maintain efficient operations while supporting quality-of-care and financial goals.
Provide information for pricing guidelines based on utilization patterns and client demographics.
Use medical background, experience, and judgment to determine whether requested services, levels of care, and sites of service should be authorized.
Apply regulatory requirements and relevant clinical guidelines, CMS policies, determinations, and reference materials in daily work.
Learn Medicare, Medicare Advantage, and/or Medicaid requirements and operationalize that knowledge.
Engage contracted physicians, physician groups, facilities, or community groups in support of regional market priorities and collaborative business relationships.
Support value-based care, population health, and disease or care management priorities as applicable.
Support Humana values and its Bold Goal mission.