Medical Director Behavioral Health, Medicaid

Humana • Remote US, IN

3d • $223,800 - $313,100 • Remote

About The Position

The Behavioral Health Medical Director is responsible for behavioral health care strategies and/or operations. You will work assignments involving moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. Responsibilities include using medical background, experience, and judgment to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and assisted by diverse resources. This includes learning Medicaid requirements and understanding how to operationalize this knowledge in daily work. Work involves computer-based review of clinical scenarios, review of submitted clinical records, prioritization of daily work, communication of decisions, and possible participation in care management. Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process, which may require conflict resolution skills. May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities. Supports Humana values including working collaboratively on a team throughout all activities. Flows to work as needed within cluster for vacations, weekends, and holidays coverage.

Requirements

• Doctor of Medicine or Doctor of Osteopathy
• Board-certified in an ABMS recognized specialty of Psychiatry
• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
• At least five years of experience post-training providing clinical services
• Experience in utilization management review and case management in a health plan setting
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
• SSN request is a reference check task that scans for duplicate profiles in our Workday ATS that will be requested at the offer stage

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
• Has a Louisiana medical license
• Has experience with application of MCG and ASAM criteria

Responsibilities

• Use your medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and assisted by diverse resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources
• Learn Medicaid requirements and understand how to operationalize this knowledge in your daily work assigned cluster
• Work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management, with clinical scenarios arising from outpatient or inpatient environments
• 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 may require conflict resolution skills
• May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes and a focus on collaborative business relationships, values-based care, population health, or disease or care management
• Supports Humana values including working collaboratively on a team throughout all activities
• Flows to work as needed within cluster as needed for vacations, weekends and holidays coverage

Benefits

• medical
• dental
• 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

What This Job Offers

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