Behavioral Health Medical Director, Medicaid

About the role

As the Behavioral Health Medical Director, you will drive behavioral health care strategy and operations. This role involves analyzing moderately complex to complex clinical scenarios and making determinations on service authorization, levels of care, and sites of service within a regulatory compliance framework. You will collaborate within a team-based environment to support Humana’s values and initiatives.

Responsibilities

• Apply medical training, clinical experience, and professional judgment to evaluate requested services, levels of care, or sites of service for authorization.
• Ensure determinations comply with regulatory requirements, supported by resources such as national clinical guidelines, state policies, CMS policies, and internal references.
• Learn and apply Medicaid requirements, operationalizing this knowledge in daily work within the assigned cluster.
• Perform computer-based reviews of clinical scenarios, including prioritizing daily work, reviewing submitted records, and communicating decisions to internal teams.
• Review clinical scenarios from outpatient and inpatient care settings.
• Conduct telephone discussions with external physicians to gather additional clinical information or discuss determinations through peer-to-peer reviews.
• Use conflict resolution skills during complex or sensitive physician discussions.
• Engage with contracted external physicians, groups, facilities, or community organizations to support regional market priorities.
• Demonstrate understanding of Humana processes and support collaborative relationships, value-based care, population health strategies, and disease/care management programs.
• Provide coverage and flexibility across the assigned cluster, including support during vacations, weekends, and holidays.

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathy (DO).
• Board-certified in an ABMS or ABPN-recognized specialty of Psychiatry (Neurology not accepted).
• Current and unrestricted medical license through the Interstate Medical Licensure Compact (IMLC) in at least one jurisdiction, with willingness to obtain additional licenses as required.
• No current sanctions from federal or state governmental organizations; must pass onboarding requirements.
• 2+ years of project management experience.
• At least five years of post-training clinical service experience.
• Experience in utilization management review and case management within a health plan setting.
• Excellent verbal and written communication skills, with analytic and interpretative abilities in quality, utilization, and case management.
• Knowledge of national guidelines such as NCD/LCD, MCG®, or InterQual.

Preferred Qualifications

• Experience working with Medicaid enrollees, providers, and stakeholders in clinical or administrative settings.
• Experience with accreditation processes (e.g., NCQA).
• Familiarity with CGX and MHK platforms.
• Licensure through the Interstate Medical Licensure Compact (IMLC).
• Indiana medical license.
• Experience applying MCG and ASAM criteria.

Work Style

This is a fully remote position. Occasional travel to Humana’s offices for training or meetings may be required.

Schedule

• Typical business hours: Monday–Friday, 8 hours/day, 5 days/week (EST zone).
• Holiday and weekend coverage may be required.
• Minimal travel may be required for training, meetings, or conferences.

License/Credential Requirements

At the time of hire, you must have an active, unencumbered medical license in at least one state within the assigned cluster (Louisiana, Oklahoma, Indiana, Ohio, Florida, Virginia, or Kentucky).

Benefits

• Benefits starting on day 1 of employment.
• Competitive 401(k) match.
• Generous paid time off accrual.
• Tuition reimbursement.
• Parental leave.

Pay

The pay range for this full-time (40 hours per week) position is $223,800 – $313,100 per year. This role is eligible for a bonus incentive plan based on company and/or individual performance.

Work at Home Requirements

• Self-provided internet service must meet minimum speeds: 25 Mbps download and 10 Mbps upload (wireless, wired cable, or DSL suggested).
• Work from a dedicated space free of ongoing interruptions to protect member PHI/HIPAA information.