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Medical Director - Medicaid

Metairie, LA, USA | Humana

  • Industry:
    Insurance - Health & Life
  • Position Type:
    Full-Time
  • Functions:
    General Management
    Biotech/R&D/Science
  • Experience:
    5-7 years
Job Description:
81 people have viewed this job

The Medical Director relies on medical background and reviews health claims. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities


Humana’s Louisiana Medicaid Medical Director will oversee our clinical programs for Louisiana Medicaid plan enrollees. They will collaborate closely with the Chief Medical Officer (CMO) and Behavioral Health (BH) Medical Director to integrate the day-to-day administration and strategic management of behavioral and health services, including care management, utilization management (UM), quality improvement, population health and value-based payment programs. The Medical Director will also lead the development of new products and services in Humana’s Medicaid clinical delivery model. They will be based in Louisiana and will report directly to the Louisiana Medicaid Chief Medical Officer (CMO).


Essential Functions and Responsibilities


Lead major clinical and quality management components of Humana’s health services

Provide clinical case management consultations and clinical guidance for contracted primary care physicians (PCPs) treating health related concerns not requiring referral to specialists

Provides overall management and strategic leadership for plan Medical Directors and ensures compliance with State, Federal and accreditation standards

Oversee, monitor and assist with effective implementation of the Quality Management (QM) program; accountable for overall continuous improvement of physical health services and programs

Oversee, monitor, and assist with the management of pharmacy benefits manager (PBM) activities, including the establishment of prior authorization, clinical appropriateness of use, and step therapy requirements for the use of stimulants for all enrollees

Work closely with the UM of services and associated appeals

Support health policy development in Louisiana, driving implementation, oversight, and accountability for both Humana internal and external stakeholders  

Adhere to and comply with federal and state laws, accreditation standards and programmatic requirements

Collaborate with provider relations personnel to ensure high-quality and appropriate care delivered through the health provider network

Establish and maintain relationships with providers, advocates, and other key Louisiana stakeholders by maintaining open and ongoing communications; represent Humana at public forums and engagement opportunities

Maintain compliance with clinical related contract requirements and attend oversight committee meetings to ensure appropriate procedures are adhered to within Humana and within our care delivery model

Collaborate closely with the Chief Population Health Officer in developing programs and strategies to address health needs at a population health level

Serve as co-chairperson of Humana’s Louisiana Quality Improvement Committee 


Required Education, Certification, & Experience Qualifications 


Physician with a current, unencumbered Louisiana-license as a physician

At least three (3) years of training in a medical specialty

Strong leadership skills to manage physicians

Knowledge of the managed care industry

Possess analysis and interpretation skills with prior experience leading teams focusing on care management, quality management, UM, discharge planning and/or home health or rehab

Preferred Experience Qualifications


At least two (2) years clinical leadership and supervisory experience

Five (5) years or more clinical experience

Familiarity with Louisiana-based clinical advocacy organizations

Medicaid Managed Care clinical leadership experience


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