Medical Director, Medicaid

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Deliver clinical leadership in the management of Medicaid behavioral health utilization.

• Evaluate intricate behavioral health requests and clinical documentation across various levels of care and specialty services.

• Implement clinical criteria, Medicaid guidelines, state regulations, evidence-based national standards, and Medicaid requirements.

• Make prompt, consistent, and justifiable determinations regarding medical necessity.

• Engage in peer-to-peer consultations and discussions.

• Assist with utilization reviews, appeals, provider disputes, state fair hearings, audits, and regulatory activities.

• Work collaboratively with providers and internal stakeholders.

• Take part in case consultations, training sessions, and process enhancement initiatives.

• Handle a high volume of time-sensitive tasks and provide coverage during absences, holidays, and on-call shifts.

• Uphold confidentiality and adhere to privacy, security, credentialing, and organizational standards.

• Report to the Lead Behavioral Health Medical Director or a designated physician leader.

⛳️ Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree.

• Board certified in psychiatry by the American Board of Psychiatry and Neurology (ABPN) or another recognized certifying body.

• Active, unrestricted medical license in Illinois at the time of hire.

• Capability to obtain and maintain additional state licenses as required for assigned Medicaid markets.

• Minimum of five years of clinical experience post-training.

• Experience in utilization management, medical necessity evaluation, peer review, or similar clinical decision-making roles.

• Exceptional written and verbal communication skills.

• Strong abilities in clinical analysis, interpretation, and conflict resolution.

• Capacity to independently manage a high-volume workload while ensuring compliance with quality and turnaround standards.

• Proven track record of effectively working in a remote setting and utilizing technology for communication, collaboration, clinical information review, and task completion.

• Eligibility to participate in federal and state healthcare programs and fulfill employment onboarding prerequisites.

• Consistent attendance and strict compliance with the assigned work schedule.

• Willingness to participate in rotating holiday and on-call duties, as applicable.

• Self-provided internet connection with a minimum download speed of 25 Mbps and upload speed of 10 Mbps.

• Dedicated workspace free from continuous interruptions to safeguard member PHI/HIPAA information.

🏝️ Benefits

• Performance-based bonus incentive plan.

• Comprehensive medical, dental, and vision coverage.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability insurance.

• Life insurance coverage.

• Limited travel for training, meetings, conferences, or other business-related activities.

• Fully remote work opportunity.

• Rotating holiday and on-call coverage, as applicable.