BH Medical Director, Medicaid

Humana • Work at Home - Illinois, IL

2d • $223,800 - $313,100 • Remote

About The Position

The Behavioral Health Medical Director provides clinical leadership for Medicaid behavioral health utilization management and makes timely, consistent, and defensible medical-necessity determinations. The role primarily supports Illinois Medicaid and may support other Medicaid markets as needed. The Behavioral Health Medical Director provides clinical leadership and supports Medicaid behavioral health utilization management operations. The physician reviews complex behavioral health requests, applies applicable clinical criteria and Medicaid policies, and makes timely, consistent, and defensible medical-necessity determinations. Responsibilities include peer-to-peer consultations, appeals, provider disputes, quality reviews, state fair hearings, audits, and regulatory activities. The Medical Director collaborates with providers and internal partners while managing high-volume, time-sensitive work. This virtual position reports to the Lead Behavioral Health Medical Director and may support multiple Medicaid markets based on business needs. Model Humana's values through teamwork, collaboration, and professionalism. Apply clinical expertise, independent judgment, evidence-based national guidelines, state regulations, and Medicaid requirements to medical-necessity reviews. Review clinical records across behavioral health levels of care and specialty services, and document clear, consistent determinations. Conduct peer-to-peer discussions and support utilization reviews, appeals, disputes, hearings, audits, and regulatory activities. Collaborate with internal and external partners and participate in case consultations, training, and process improvement. Manage high-volume, time-sensitive work, adapt to changing requirements, and provide coverage during planned and unplanned absences, holidays, and on-call rotations. Maintain confidentiality and comply with privacy, security, credentialing, and organizational requirements.

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board certified in psychiatry by the American Board of Psychiatry and Neurology (ABPN) or another recognized certifying board.
• Active, unrestricted Illinois medical license at the time of hiring, with the ability to obtain and maintain additional state licenses as needed for assigned Medicaid markets.
• At least five years of post-training clinical experience.
• Experience in utilization management, medical-necessity review, peer review, or comparable clinical decision-making.
• Excellent written and verbal communication skills, with strong clinical analysis, interpretation, and conflict-resolution abilities.
• Demonstrated ability to independently manage a high-volume workload while meeting quality, compliance, and turnaround requirements.
• Experience working effectively in a remote environment and using technology to communicate, collaborate, review clinical information, and complete assigned work.
• Eligibility to participate in federal and state healthcare programs and ability to meet employment onboarding requirements.

Nice To Haves

• Two or more years of recent utilization management, medical-necessity review, or physician review experience in a health plan, managed care organization, or comparable setting.
• Prior experience as a medical director, associate medical director, or physician reviewer.
• Demonstrated knowledge of Medicaid requirements, applicable state regulations, and evidence-based national guidelines, with experience applying them within assigned workflows.
• Substantial experience with complex peer-to-peer reviews, appeals, provider disputes, state fair hearings, quality reviews, or regulatory audits.
• Training or substantial experience in addiction-psychiatry or child and adolescent psychiatry.
• Experience with autism services, applied behavior analysis, psychological or neuropsychological testing, or psychometric principles.
• Experience with serious mental illness, substance use disorders, intellectual or developmental disabilities, or complex child and adolescent behavioral health needs.
• Eligibility for participation in the Interstate Medical Licensure Compact.

Responsibilities

• Provides clinical leadership for Medicaid behavioral health utilization management.
• Makes timely, consistent, and defensible medical-necessity determinations.
• Reviews complex behavioral health requests.
• Applies applicable clinical criteria and Medicaid policies.
• Conducts peer-to-peer consultations.
• Handles appeals, provider disputes, quality reviews, state fair hearings, audits, and regulatory activities.
• Collaborates with providers and internal partners.
• Manages high-volume, time-sensitive work.
• Applies clinical expertise, independent judgment, evidence-based national guidelines, state regulations, and Medicaid requirements to medical-necessity reviews.
• Reviews clinical records across behavioral health levels of care and specialty services, and documents clear, consistent determinations.
• Conducts peer-to-peer discussions and supports utilization reviews, appeals, disputes, hearings, audits, and regulatory activities.
• Collaborates with internal and external partners and participates in case consultations, training, and process improvement.
• Manages high-volume, time-sensitive work, adapts to changing requirements, and provides coverage during planned and unplanned absences, holidays, and on-call rotations.
• Maintains confidentiality and complies with privacy, security, credentialing, and organizational requirements.

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: Mid Level
• Education Level: Ph.D. or professional degree