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.
The Behavioral Health Medical Director provides clinical leadership and supports Medicaid behavioral health utilization management operations. The physician 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, and regulatory activities. The Medical Director 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.
- Model Humana's values through teamwork, collaboration, and professionalism.
- Apply clinical expertise, independent judgment, evidence-based national guidelines, state regulations, and Medicaid requirements to medical-necessity reviews.
- Review clinical records across behavioral health levels of care and specialty services, and document clear, consistent determinations.
- Conduct peer-to-peer discussions and support utilization reviews, appeals, disputes, hearings, audits, and regulatory activities.
- Collaborate with internal and external partners and participate in case consultations, training, and process improvement.
- Manage high-volume, time-sensitive work, adapt to changing requirements, and provide coverage during planned and unplanned absences, holidays, and on-call rotations.
- Maintain confidentiality and comply with privacy, security, credentialing, and organizational requirements.
Use your skills to make an impact Required 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. This technology provides our team of recruiters and hiring managers with an enhanced method for decision-making through on-demand candidate assessments.
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. You should anticipate the assessment to take approximately 10-15 minutes.
Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.
SSN Task via WorkdayShould you receive a formal employment offer you will receive a request to enter your SSN into our ATS system to scan for duplicate profiles.
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours40
Pay RangeThe 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. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$223,800 - $313,100 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.
