[Remote] Behavioral Health Medical Director - Medicare at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

MD or DO degree
Must be board certified in Psychiatry
5+ years of direct clinical patient care experience post residency or fellowship, preferably including 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

Responsibilities

Develop behavioral health care strategy and/or operations
Use medical background, experience, and judgement to make determinations on whether requested services, level of care, and/or site of service should be authorized, within a context of regulatory compliance
Learn Medicare, Medicare Advantage and Medicaid requirements, and operationalize this knowledge in daily work
Attend and participate in meetings involving care management, provider relations, quality of care, audit, grievance and appeal, and policy review
Develop and present educational seminars on various behavioral health topics to the clinical operations team and healthcare organization
Perform computer-based review of moderately complex to complex clinical scenarios, review submitted clinical records, prioritize daily work, and communicate decisions to internal associates
Participate in care management and have discussions with external physicians by phone to gather additional clinical information or discuss determinations, including conflict resolution
Speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, focusing on collaborative business relationships, value-based care, quality metrics, population health, and disease or care management
Develop procedures, processes, productivity targets, and new delivery models to maintain efficient operations while ensuring quality of care and financial goals
Support Humana values and Humana’s Bold Goal mission throughout all activities

Skills

Key technologies and capabilities for this role

Behavioral HealthMedical DirectorMedicareMedicare AdvantageMedicaidUtilization ReviewClinical GuidelinesCMS PoliciesCare ManagementProvider RelationsQuality of CareGrievance and AppealPolicy Review

Questions & Answers

Common questions about this position

What are the required qualifications for the Behavioral Health Medical Director role?

Candidates must have an MD or DO degree, be board certified in Psychiatry, and possess 5+ years of direct clinical patient care experience post residency or fellowship, preferably including behavioral health.

What is the salary or compensation for this position?

This information is not specified in the job description.

Is this a remote position or does it require office work?

This information is not specified in the job description.

What does the company culture emphasize for this role?

The role involves joining a caring community to put health first, supporting Humana values and the Bold Goal mission, with a focus on collaborative relationships, value-based care, and quality metrics.

What experience makes a strong candidate for this position?

Strong candidates will have board certification in Psychiatry, 5+ years of post-residency direct patient care experience preferably in behavioral health, and skills in clinical review, regulatory compliance, and physician communication.

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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