Behavioral Health Medical Director - Medicare

The Behavioral Health Medical Director is responsible for developing and implementing behavioral health care strategy and operations. This role involves making determinations on the authorization of requested services, level of care, and site of service based on medical background, experience, and judgment, while adhering to regulatory compliance and utilizing resources like national clinical guidelines and CMS policies. The director will learn and operationalize Medicare, Medicare Advantage, and Medicaid requirements, participate in meetings related to care management, provider relations, quality of care, audits, grievances, and policy review, and develop and present educational seminars on behavioral health topics. Responsibilities include computer-based review of clinical scenarios, review of clinical records, prioritizing daily work, communicating decisions, and potentially participating in care management. The role involves discussions with external physicians to gather clinical information or discuss determinations, which may require conflict resolution skills. Additionally, the Medical Director may engage with external physicians, groups, and facilities to support regional market priorities, potentially developing procedures, processes, productivity targets, and new delivery models to ensure efficient operations and achieve quality of care and financial goals, all while supporting Humana values and its Bold Goal mission.