Medical Director, Medicaid

Job not on LinkedIn

🔥 1 hour ago

🌽 Illinois – Remote

🌽 Illinois – 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

• Provide clinical leadership for Medicaid behavioral health utilization management • Review complex behavioral health requests and clinical records across levels of care and specialty services • Apply clinical criteria, Medicaid policies, state regulations, evidence-based national guidelines, and Medicaid requirements • Make timely, consistent, and defensible medical-necessity determinations • Conduct peer-to-peer consultations and discussions • Support utilization reviews, appeals, provider disputes, state fair hearings, audits, and regulatory activities • Collaborate with providers and internal partners • Participate in case consultations, training, and process improvement • Manage high-volume, time-sensitive work and provide coverage during absences, holidays, and on-call rotations • Maintain confidentiality and comply with privacy, security, credentialing, and organizational requirements • Report to the Lead Behavioral Health Medical Director or another designated physician leader

🎯 Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) • Board certified in psychiatry by the American Board of Psychiatry and Neurology (ABPN) or another recognized certifying board • Active, unrestricted Illinois medical license at the time of hiring • Ability to obtain and maintain additional state licenses as needed for assigned Medicaid markets • At least five years of post-training clinical experience • Experience in utilization management, medical-necessity review, peer review, or comparable clinical decision-making • Excellent written and verbal communication skills • Strong clinical analysis, interpretation, and conflict-resolution abilities • Ability to independently manage a high-volume workload while meeting quality, compliance, and turnaround requirements • Experience working effectively in a remote environment and using technology to communicate, collaborate, review clinical information, and complete assigned work • Eligibility to participate in federal and state healthcare programs and ability to meet employment onboarding requirements • Reliable attendance and strict adherence to the assigned work schedule • Participation in rotating holiday and on-call coverage, as applicable • Self-provided internet service with at least 25 Mbps download and 10 Mbps upload speed • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • 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 • Limited travel for training, meetings, conferences, or other business purposes • Fully remote work • Rotating holiday and on-call coverage, as applicable