Lead Medical Director - BH/MH

Humana • Louisiana, SC

2d • Remote

About The Position

Become a part of our caring community The Behavioral Health Cluster Lead Medical Director manages a team of Behavioral Health Medical Directors who primarily conduct Behavioral Health case reviews of the care received by members with a Behavioral Health benefit in designated markets. The Behavioral Health Cluster Lead Medical Director may provide medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Some decisions will be related to identifying and resolving complex technical and operational problems within the BH department. Supervisory responsibility of at minimum 4-5 other physicians (and perhaps clinicians) is expected. The individual in this role may lead other highly specialized professional associates (i.e., behavioral health or other subspecialists. Responsibilities Participates in required state Behavioral Health administrative activities in their state of licensure and monitors requirements for other states assigning duties to Behavioral Health physicians or designated representatives. Uses their medical background, experience, and judgement in addition to state guidelines and national criteria, to make determinations whether requested services, requested level of care, or requested site of service should be authorized. Uses their medical background and experience in leading interdisciplinary rounds and providing clinical guidance and support to Behavioral Health Care Managers and other Behavioral Health associates as indicated. Attends Behavioral Health Fair Hearings Oversees and helps to implement the Behavioral Health IRR process to measure consistency in medical decision making across Behavioral Health markets. Oversees work performed by Behavioral Health Medical Directors within our Medicaid program. Develops, implements, and trains medical directors on the use of Behavioral Health adverse determination templates as well as BH policies and guidelines, PAL, and work associated clinical systems to ensure compliance with audits and accrediting agencies (i.e., NCQA). Also provides training across the Medicaid enterprise on the role of the health plan’s Behavioral Health medical director in Fair Hearings. Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process; and in some instances, these discussions may require conflict resolution skills. Oversees clinical documentation including adverse determination letter templates, grievance, and appeals processes (including pharmacy if applicable) in Behavioral Health members May occasionally speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities. Support Humana’s values and our enterprise social needs team mission throughout all activities. Additional Expectations Conduct Behavioral Health authorization reviews Provide Behavioral Health specific training on case reviews and determinations Work alongside other Cluster Leads to ensure fair distribution of workload and adequate coverage and staffing for reviews. Review and evaluate all Behavioral Health MD requests for PTO and CME Contribute to budget planning review (license renewals, CME) Actively participate in On Call” schedule to ensure coverage amongst Behavioral Health medical directors Manage their medical director team to include any Human Resource requirements The Lead Medical Director may also lead specific functional area in addition to leading a team of Medical Directors. Must be passionate about contributing to an organization focused on continuously improving consumer experiences Use your skills to make an impact

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathy (DO)
• Board-certified in Psychiatry (ABPN)
• An active and unrestricted license in at least one jurisdiction and willing to obtain a license, as required, for various states in region of assignment
• At least five years of experience post-residency/internship providing clinical services
• 2+ years of management experience
• Experience in utilization management review and case management in a health plan setting
• Experience with evidence-based guidelines utilized in assisting with determinations (e.g. MCG)
• Physician with an active, unencumbered license in at least one of the states that are part of the Humana Medicaid group of clusters.

Nice To Haves

• Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
• Internal Medicine, Family Practice, Geriatrics, Hospitalist clinical specialists
• Previous Medicare, Medicaid, and/or Commercial experience
• Experience with accreditation process preferred (NCQA)
• Experience in the clinical conditions associated with aging and disability.
• Experience in Addiction specialty as outlined by ASAM credentials.

Responsibilities

• Participates in required state Behavioral Health administrative activities in their state of licensure and monitors requirements for other states assigning duties to Behavioral Health physicians or designated representatives.
• Uses their medical background, experience, and judgement in addition to state guidelines and national criteria, to make determinations whether requested services, requested level of care, or requested site of service should be authorized.
• Uses their medical background and experience in leading interdisciplinary rounds and providing clinical guidance and support to Behavioral Health Care Managers and other Behavioral Health associates as indicated.
• Attends Behavioral Health Fair Hearings
• Oversees and helps to implement the Behavioral Health IRR process to measure consistency in medical decision making across Behavioral Health markets.
• Oversees work performed by Behavioral Health Medical Directors within our Medicaid program.
• Develops, implements, and trains medical directors on the use of Behavioral Health adverse determination templates as well as BH policies and guidelines, PAL, and work associated clinical systems to ensure compliance with audits and accrediting agencies (i.e., NCQA). Also provides training across the Medicaid enterprise on the role of the health plan’s Behavioral Health medical director in Fair Hearings.
• Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process; and in some instances, these discussions may require conflict resolution skills.
• Oversees clinical documentation including adverse determination letter templates, grievance, and appeals processes (including pharmacy if applicable) in Behavioral Health members
• May occasionally speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities.
• Support Humana’s values and our enterprise social needs team mission throughout all activities.
• Conduct Behavioral Health authorization reviews
• Provide Behavioral Health specific training on case reviews and determinations
• Work alongside other Cluster Leads to ensure fair distribution of workload and adequate coverage and staffing for reviews.
• Review and evaluate all Behavioral Health MD requests for PTO and CME
• Contribute to budget planning review (license renewals, CME)
• Actively participate in On Call” schedule to ensure coverage amongst Behavioral Health medical directors
• Manage their medical director team to include any Human Resource requirements

Benefits

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

What This Job Offers

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