[Hiring] Behavioral Health Medical Director @Humana

Role Description

The Behavioral Health Medical Director provides clinical leadership for Medicaid behavioral health utilization management and makes timely, consistent, and defensible medical-necessity determinations. The role primarily supports Illinois Medicaid and may support other Medicaid markets as needed.

• Provides clinical leadership and supports Medicaid behavioral health utilization management operations.
• Reviews complex behavioral health requests, applies applicable clinical criteria and Medicaid policies, and makes timely, consistent, and defensible medical-necessity determinations.
• Responsibilities include:
  • Peer-to-peer consultations
  • Appeals
  • Provider disputes
  • Quality reviews
  • State fair hearings
  • Audits
  • Regulatory activities
• Collaborates with providers and internal partners while managing high-volume, time-sensitive work.
• This virtual position reports to the Lead Behavioral Health Medical Director and may support multiple Medicaid markets based on business needs.
• Models Humana's values through teamwork, collaboration, and professionalism.
• Applies clinical expertise, independent judgment, evidence-based national guidelines, state regulations, and Medicaid requirements to medical-necessity reviews.
• Reviews clinical records across behavioral health levels of care and specialty services, and documents clear, consistent determinations.
• Conducts peer-to-peer discussions and supports utilization reviews, appeals, disputes, hearings, audits, and regulatory activities.
• Collaborates with internal and external partners and participates in case consultations, training, and process improvement.
• Manages high-volume, time-sensitive work, adapts to changing requirements, and provides coverage during planned and unplanned absences, holidays, and on-call rotations.
• Maintains confidentiality and complies with privacy, security, credentialing, and organizational requirements.

Qualifications

• 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, with the 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, with strong clinical analysis, interpretation, and conflict-resolution abilities.
• Demonstrated 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.

Preferred Qualifications

• Two or more years of recent utilization management, medical-necessity review, or physician review experience in a health plan, managed care organization, or comparable setting.
• Prior experience as a medical director, associate medical director, or physician reviewer.
• Demonstrated knowledge of Medicaid requirements, applicable state regulations, and evidence-based national guidelines, with experience applying them within assigned workflows.
• Substantial experience with complex peer-to-peer reviews, appeals, provider disputes, state fair hearings, quality reviews, or regulatory audits.
• Training or substantial experience in addiction-psychiatry or child and adolescent psychiatry.
• Experience with autism services, applied behavior analysis, psychological or neuropsychological testing, or psychometric principles.
• Experience with serious mental illness, substance use disorders, intellectual or developmental disabilities, or complex child and adolescent behavioral health needs.
• Eligibility for participation in the Interstate Medical Licensure Compact.

Work Style

• Schedule: Standard work hours are Monday through Friday, 8:00 a.m. to 5:00 p.m., aligned to either Eastern or Central Time based on the assigned schedule.
• Work Location: This position is designated as fully remote.
• Coverage Requirements: Reliable attendance and strict adherence to the assigned work schedule are essential. This role also requires participation in rotating holiday and on-call coverage, as applicable.
• Travel Requirements: Limited travel may be required for training, meetings, conferences, or other business-related purposes.

Reporting Relationship

• Reports to the Lead Behavioral Health Medical Director or another designated physician leader.

Interview Format

• As part of our hiring process, we will be using on-demand technology provided by HireVue, a third-party vendor.
• If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions.
• Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to the next round of interviews.

Work at Home Requirements

• To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service must meet the following criteria:
  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required.
  • Wireless, wired cable or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
• While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

• 40

Pay Range

• The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting: $223,800 - $313,100 per year.
• This job is eligible for a bonus incentive plan based upon company and/or individual performance.

Description of Benefits

• Humana, Inc. offers competitive benefits that support whole-person well-being, including:
  • Medical, dental and vision benefits
  • 401(k) retirement savings plan
  • Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
  • Short-term and long-term disability
  • Life insurance
  • Many other opportunities