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 moderately complex to complex assignments requiring in-depth analysis of clinical situations and data. You will work collaboratively within a team-based environment to support Humana’s values and initiatives.

Responsibilities

• Apply medical training, clinical experience, and professional judgment to authorize requested services, levels of care, or sites of service.
• Ensure all determinations comply with regulatory frameworks and are supported by appropriate resources, including 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 moderately complex to complex clinical scenarios, including reviewing submitted records, prioritizing work, communicating decisions, and participating in care management activities.
• 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 physician discussions, especially in complex or sensitive situations.
• Engage with contracted external physicians, groups, facilities, or community organizations to support regional market priorities.
• Demonstrate understanding of Humana’s processes and support collaborative relationships, value-based care initiatives, population health strategies, and disease or 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 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 strong analytic and interpretative abilities in quality, utilization, and 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 clinical or administrative settings.
• Experience with accreditation processes (e.g., NCQA).
• Experience with CGX and MHK.
• 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 are Monday–Friday, 8 hours/day, 5 days/week (EST zone). This role may require working holidays and weekends. 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).

Reporting Relationship

This position reports directly to the Cluster Lead Medical Director.

Benefits

• Benefits starting on 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 minimum requirements: download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable, or DSL suggested).
• Work from a dedicated space free of ongoing interruptions to protect member PHI/HIPAA information.