Behavioral Health Medical Director, Medicaid

About this role

Become a part of our caring community   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.

Use your skills to make an impact   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

Preferred: • 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

Work Style: Fully Remote Occasional travel to Humana's offices for training or meetings may be required.

Work Hours : Typical business hours are Monday-Friday: 8 hours/day, 5 days/week EST zone and can sit anywhere in the US. There are holiday and weekend requirements for this role. Very minimal travel might be required for training, meetings, and/or conferences

License/Credential Requirement At the time of hire, physician must have an active, unencumbered license in at least one of the states that are part of the specific cluster (Louisiana, Oklahoma, Indiana, Ohio, Florida, Virginia, Kentucky).

Reporting Relationship: This position reports directly to the Cluster Lead Medical Director.

How We Value You   • Benefits starting day 1 of employment 

• Competitive 401k match  

• Generous Paid Time Off accrual  

• Tuition Reimbursement 

• Parental Leave 

Interview Process As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making through on-demand candidate assessments.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions. You should anticipate the assessment to take approximately 10-15 minutes.

Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

SSN Task via Workday Should you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.   Travel: While this is a remote position, oc

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