BH/MH Medical Director - Medicare
2 days ago
Albany
Become a part of our caring community The Behavioral Health Medical Director is responsible for behavioral health care strategy and/or operations. The Behavioral Health Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. Become a part of our caring community and help us put health first The Behavioral Health Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs within a context of regulatory compliance and work is assisted by diverse resources which may include national clinical guidelines, CMS policies and determinations, Medicaid state contracts, clinical reference materials, internal teaching conferences, and other sources of expertise. The Behavioral Health Medical Directors will learn Medicare, Medicare Advantage and Medicaid requirements, and will understand how to operationalize this knowledge in their daily work. The Behavioral Health Medical Director will attend and participate in meetings involving care management, provider relations, quality of care, audit, grievance and appeal and policy review. The Behavioral Health Medical Director will develop and present educational seminars on various behavioral health topics to the clinical operations team and healthcare organization. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances these may require conflict resolution skills. The Behavioral Health Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value-based care, quality metrics, population health, and disease or care management. The Behavioral Health Medical Director may develop procedures, processes, productivity targets and new delivery models maintaining efficient operations while ensuring attainment of quality of care and financial goals. The Behavioral Health Medical Directors support Humana values, and Humana's Bold Goal mission, throughout all activities. Use your skills to make an impact Use your skills to make an impact Required Qualifications * MD or DO degree * Must be board certified in Psychiatry * 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare or Medicaid type population * Current and ongoing Board Certification in an approved ABMS Medical or ABPN Specialty * A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required * No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements * Excellent verbal and written communication skills * Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation * Fully remote schedule Mon-Fri 9am-6pm EST (nationwide) w/weekends as needed Preferred Qualifications * Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid products, or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management * Utilization management experience in a medical management review organization, such as Medicare Advantage and managed Medicaid * Experience with national guidelines such as MCG, ASAM or InterQual * Advanced degree such as an MBA, MHA, MPH- Exposure to Public Health, Population Health, analytics, and use of business metrics * Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health * The curiosity to learn, the flexibility to adapt and the courage to innovate Additional Information Typically reports to an Associate Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business. Work at Home Guidance To ensure Home or Hybrid Home/Office associates have the self-provided internet service you must meet the following criteria: * At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested * Leadership approves satellite, cellular and microwave connection for use only if they give approval. * Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. * Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet our requirements for their position/job. * 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 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. 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 Benefits Humana, 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 09-12-2026 About us About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. ? Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our .
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