Behavioral Health Medical Director, Medicaid

🔥 0 minutes ago

🐊 Florida, Kentucky, +4 more states – Remote

🐊 Florida – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote ⚔️ Virginia – Remote

💵 $223.8k - $313.1k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Develop and support behavioral health care strategy and/or operations • Determine whether requested services, levels of care, or sites of service should be authorized • Make determinations within a regulatory compliance framework using clinical guidelines, state and CMS policies, and other applicable resources • Learn and operationalize Medicaid requirements within the assigned cluster • Perform computer-based reviews of moderately complex to complex clinical scenarios • Review submitted clinical records and prioritize daily work • Communicate decisions to internal associates and potentially participate in care management activities • Review outpatient and inpatient clinical scenarios • Conduct telephone discussions with external physicians through peer-to-peer review • Use conflict resolution skills during complex or sensitive physician discussions • Engage with contracted external physicians, physician groups, facilities, and community organizations • Support regional market priorities, value-based care initiatives, population health strategies, and disease or care management programs • Provide coverage and flex across the assigned cluster, including vacations, weekends, and holidays • Report directly to the Cluster Lead Medical Director

🎯 Requirements

• Doctor of Medicine or Doctor of Osteopathy • Board-certified in an ABMS or ABPN recognized specialty of Psychiatry; Neurology not accepted • Current and unrestricted license through the Interstate Medical Licensure Compact in at least one jurisdiction • Willingness to obtain additional licenses when required • No current sanction from Federal or State Governmental organizations • Ability 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 • Analytic and interpretative skills focused on quality, utilization, and/or case management • Knowledge and experience with national guidelines such as NCD/LCD, MCG®, or InterQual • At the time of hire, an active, unencumbered license in at least one state in the specific cluster: Louisiana, Oklahoma, Indiana, Ohio, Florida, Virginia, or Kentucky • Typical work hours Monday-Friday, 8 hours/day, 5 days/week in the EST zone • Ability to meet work-from-home requirements, including a minimum 25 Mbps download and 10 Mbps upload internet connection • Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Benefits starting day 1 of employment • Competitive 401k match • Generous Paid Time Off accrual • Tuition Reimbursement • Parental Leave • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off, company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Bonus incentive plan • Occasional travel to Humana's offices for training or meetings may be required