Behavioral Health Medical Director, Medicaid

Become a part of our caring community as a Behavioral Health Medical Director, shaping behavioral health care strategy and operations. This role involves analyzing moderately complex to complex issues and collaborating effectively within a team-based environment.

Responsibilities

• 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, including national clinical guidelines, state policies, CMS policies, and clinical reference materials.
• Learn and apply Medicaid requirements, operationalizing this knowledge in daily work within the assigned cluster.
• Perform computer-based reviews of moderately complex to complex clinical scenarios, including review of submitted clinical records, prioritization of daily work, and communication of decisions to internal associates.
• Participate in care management activities as needed.
• Review clinical scenarios 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 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.
• Provide coverage and flexibility across the assigned cluster, including support for 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).
• A current and unrestricted license through the Interstate Medical Licensure Compact in at least one jurisdiction, with willingness to obtain additional licenses as required.
• No current sanctions 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 abilities 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 Qualifications

• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting.
• Experience with the accreditation process (NCQA).
• Experience with CGX and MHK.
• Licensure through the Interstate Medical Licensure Compact (IMLC).
• Indiana medical license.
• Experience with application of MCG and ASAM criteria.

Schedule

• Fully remote position with occasional travel to Humana's offices for training or meetings.
• Typical business hours: Monday-Friday, 8 hours/day, 5 days/week (EST zone).
• Holiday and weekend requirements may apply.
• Minimal travel may be required for training, meetings, or conferences.

License/Credential Requirements

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

Benefits

• Benefits starting day 1 of employment.
• Competitive 401k 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 the following criteria: minimum download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable, or DSL connection suggested).
• Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.