Bridgeport, CT, United States
Dec 20, 2022
The Behavioral Health Medical Director makes determinations regarding prior authorization and retrospective reviews for inpatient and outpatient services to ensure that members receive clinically appropriate and medically necessary services. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources which may include national clinical guidelines, Humana contract language, Humana coverage policies and determinations, medical necessity criteria, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare, Medicaid, and Commercial requirements and will understand how to operationalize this knowledge in their daily work.
The Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
The Behavioral Health Medical Director's work includes computer-based review of moderately to highly 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. The clinical scenarios predominantly arise from inpatient, post-acute care environments, outpatient service requests, ER review, pharmacy review work, and appeal case review. The Medical Director reviews clinical documentation and has discussions with external physicians by phone to gather additional clinical information or discuss determinations on a regular basis. In some instances these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. The 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, population health, and/or disease/care management. Medical Directors support Humana values, and Humana's Bold Goal mission, throughout all activities.
The Behavioral Health Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with medical necessity criteria, national guidelines, state mandates, contract language, and Humana policies. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Healthcare Clinical Operations. After completion of structured and mentored training, daily work is performed with minimal direction but with ready support from other team members. The Medical Director enjoys working in a structured environment with expectations for consistency in thinking and authorship, exercises independence in meeting departmental expectations and meets compliance timelines. The Behavioral HeaMedical Director supports the assigned work with respect to market-wide objectives (e.g. Bold Goal) and community relations as directed.
Makes determinations regarding prior authorization and retrospective reviews for inpatient and outpatient services
Performs concurrent stay reviews for inpatient services, including rounds with case management teams
Performs Peer to Peer consultation as needed during medical necessity review process or upon request of the provider treating the member
Supports and processes Grievances and Appeal cases as needed
Conducts clinical education and training for other Humana associates and Humana members
Supports pharmacy regarding clinical policies regarding prior authorization, quality, and coverage
Performs shaping of current episode of Behavioral Health care as needed
Participates in HCO MD Inter-Rater Reliability (IRR) testing, annually
Participates in Clinical Policy Development forum and Technology Assessment Forum
Collaborates/supports clinical and market leaders in provider engagement to identify opportunities to improve health care outcomes, health care delivery, and operational efficiency
Collaborates with Clinical Learning and Development to create clinical training and educational materials
Engages with key internal stakeholders that provide services and support to Humana and/or directly to customers
Participates in corporate-wide committees
Performs quality of care reviews
Other duties as assigned
Additional Job Description
MD or DO degree
Current and ongoing active Board Certification in Psychiatry or Child Adolescent Psychiatry
5 years of direct clinical patient care experience post residency or fellowship, which preferably includes experience in an inpatient or outpatient environment related to care of Commercial patients
A current and unrestricted state medical license
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
Must have good computer and keyboarding (typing) skills
Positive team-based attitude and enjoys thriving in a changing environment with the curiosity to learn, the flexibility to adapt and the courage to innovate
Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial 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, managed Medicaid, or Commercial health insurance.
Experience with national medical necessity guidelines such as MCG® or InterQual
Addiction Medicine and/or Geriatric Psychiatry
Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health
Will report to a Lead Medical Director or Physician Director. The Medical Director conducts Utilization Management of the care received by members in an assigned line of business, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams, organizational committees, and educational forums.
Scheduled Weekly Hours
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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