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The Behavioral Health Cluster Lead Medical Director manages a team of Behavioral Health Medical Directors who primarily conduct Behavioral Health case reviews of the care received by members with a Behavioral Health benefit in designated markets.

The Behavioral Health Cluster Lead Medical Director may provide medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Some decisions will be related to identifying and resolving complex technical and operational problems within the BH department. Supervisory responsibility of at minimum 4-5 other physicians (and perhaps clinicians) is expected. The individual in this role may lead other highly specialized professional associates (i.e., behavioral health or other subspecialists.

Responsibilities

• Participates in required state Behavioral Health administrative activities in their state of licensure and monitors requirements for other states assigning duties to Behavioral Health physicians or designated representatives.

• Uses their medical background, experience, and judgement in addition to state guidelines and national criteria, to make determinations whether requested services, requested level of care, or requested site of service should be authorized. 

• Uses their medical background and experience in leading interdisciplinary rounds and providing clinical guidance and support to Behavioral Health Care Managers and other Behavioral Health associates as indicated.

• Attends Behavioral Health Fair Hearings

• Oversees and helps to implement the Behavioral Health IRR process to measure consistency in medical decision making across Behavioral Health markets. 

• Oversees work performed by Behavioral Health Medical Directors within our Medicaid program.

• Develops, implements, and trains medical directors on the use of Behavioral Health adverse determination templates as well as BH policies and guidelines, PAL, and work associated clinical systems to ensure compliance with audits and accrediting agencies (i.e., NCQA). Also provides training across the Medicaid enterprise on the role of the health plan’s Behavioral Health medical director in Fair Hearings.

• Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process; and in some instances, these discussions may require conflict resolution skills. 

• Oversees clinical documentation including adverse determination letter templates, grievance, and appeals processes (including pharmacy if applicable) in Behavioral Health members 

• May occasionally speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities.

• Support Humana’s values and our enterprise social needs team mission throughout all activities.

Additional Expectations

• Conduct Behavioral Health authorization reviews

• Provide Behavioral Health specific training on case reviews and determinations

• Work alongside other Cluster Leads to ensure fair distribution of workload and adequate coverage and staffing for reviews.  

• Review and evaluate all Behavioral Health MD requests for PTO and CME

• Contribute to budget planning review (license renewals, CME)

• Actively participate in On Call” schedule to ensure coverage amongst Behavioral Health medical directors

• Manage their medical director team to include any Human Resource requirements         

• The Lead Medical Director may also lead specific functional area in addition to leading a team of Medical Directors.      

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences  

         

Use your skills to make an impact
 

Reporting Structure

This position reports directly to the Director, Physician Leadership

This position supervises at minimum 4-5 other physicians (and perhaps clinicians)

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathy (DO)

• Board-certified in Psychiatry (ABPN)

• An active and unrestricted license in at least one jurisdiction and willing to obtain a license, as required, for various states in region of assignment

• At least five years of experience post-residency/internship providing clinical services 

• 2+ years of management experience

• Experience in utilization management review and case management in a health plan setting

• Experience with evidence-based guidelines utilized in assisting with determinations (e.g. MCG)

Preferred

• Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.

• Internal Medicine, Family Practice, Geriatrics, Hospitalist clinical specialists

• Previous Medicare, Medicaid, and/or Commercial experience

• Experience with accreditation process preferred (NCQA)

• Experience in the clinical conditions associated with aging and disability.

• Experience in Addiction specialty as outlined by ASAM credentials.

License/Credential Requirement

Physician with an active, unencumbered license in at least one of the states that are part of the Humana Medicaid group of clusters.

This role is based virtually in one of the following states: Virginia, Louisiana, Oklahoma, Indiana, Ohio, South Carolina and may require travel up to 25% of the time.

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.

 

$270,800 - $378,800 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.

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.

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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.