Behavioral Health Medical Director - Medicare

About the Role

Employment Type: Full time

Become a part of our caring community and help us put health first. The Behavioral Health Medical Director is responsible for behavioral health care strategy and/or operations. The Behavioral Health Medical Director's work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

• Actively uses their medical background, experience, and judgment 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.
• Will learn Medicare, Medicare Advantage and Medicaid requirements, and will understand how to operationalize this knowledge in their daily work.
• Will attend and participate in meetings involving care management, provider relations, quality of care, audit, grievance and appeal and policy review.
• Will develop and present educational seminars on various behavioral health topics to the clinical operations team and healthcare organization.
• 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.
• 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.
• May develop procedures, processes, productivity targets and new delivery models maintaining efficient operations while ensuring attainment of quality of care and financial goals.
• Supports Humana values, and Humana’s Bold Goal mission, throughout all activities.

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

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 grou