• The Behavioral Health Medical Director is responsible for behavioral health care strategy and/or operations. • The Behavioral Health 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. • Actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. • All work occurs within a context of regulatory compliance and work is assisted by diverse resources which may include national clinical guidelines, CMS policies and determinations, Medicaid state contracts, clinical reference materials, internal teaching conferences, and other sources of expertise. • Learn Medicare, Medicare Advantage and Medicaid requirements, and will understand how to operationalize this knowledge in their daily work. • Attend and participate in meetings involving care management, provider relations, quality of care, audit, grievance and appeal and policy review. • Develop and present educational seminars on various behavioral health topics to the clinical operations team and healthcare organization. • Includes computer based review of moderately complex to 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. • Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances these may require conflict resolution skills. • 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, quality metrics, population health, and disease or care management. • May develop procedures, processes, productivity targets and new delivery models maintaining efficient operations while ensuring attainment of quality of care and financial goals.

• Provide clinical oversight and medical direction for vision related programs and services. • Ensure clinical policies, guidelines, and practices align with evidence based ophthalmology standards and applicable regulatory requirements. • Serve as the senior clinical authority for ophthalmology related questions, escalations, and complex case reviews. • Ensure compliance with GAAP, healthcare-specific regulations, and internal policies. • Perform and oversee utilization management reviews related to ophthalmology and vision services. • Conduct medical necessity determinations for prior authorization, concurrent, and retrospective reviews. • Review and adjudicate clinical appeals and denials, including peer to peer discussions with ordering and rendering providers. • Collaborate with operational and compliance teams to ensure utilization management activities meet contractual, regulatory, and accreditation standards. • Act as a client‑facing clinical leader and ophthalmology specialist for Health Network One’s vision service lines. • Participate in client meetings, presentations, and consultations to explain clinical programs, utilization management decisions, and outcomes. • Support client relationships, retention, and growth by providing credible, thoughtful clinical guidance. • Represent Health Network One with external stakeholders, including health plans, provider partners, and regulatory entities, as appropriate. • Partner with the CEO and executive leadership team to support strategic planning, clinical program design, and growth initiatives for vision services. • Provide clinical insight to inform organizational decision making, risk management, and performance improvement efforts. • Contribute to the development and refinement of clinical workflows, quality initiatives, and performance metrics aligned with organizational goals. • Ensure compliance with federal and state regulations, accreditation standards, and client contractual requirements. • Support quality management activities related to ophthalmology and vision services, including audits, reporting, and corrective action planning. • Promote a culture of clinical excellence, accountability, and patient centered decision making.

Role Description A Medical Principal performs medical review and case management activities. The physician provides clinical insight to the organization through peer review, benefit review, consultation, and service to internal and external customers. He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims). This is an entry to mid-level position for a physician interested in a career in health care administration. - Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles. - Works to achieve quality outcomes for customers/members with a focus on service and cost. - Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills. - Balances customer/member needs with business needs while serving as a customer/member advocate at all times. - Participates in all levels of the Appeal process as appropriate and allowed by applicable regulatory agencies and accreditation organizations. - Participates in coverage guideline development, development and maintenance of medical management projects, initiatives and committees. - Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects. - Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes. - Improves health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information and the fostering of positive collegial relationships. - Demonstrates knowledge as a peer reviewer by applying current evidence-based guidelines, including novel treatments, to support high-quality clinical decision-making across medical and behavioral health conditions, diseases, treatments, and procedures. - Addresses customer service issues with mentoring and support from leadership staff. - Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff. - Achieves internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions. - Provides clinical insight and management support to other functional areas and matrix partners as needed or directed. Qualifications - Current unrestricted medical license in a US state or territory. - Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty. - Exhibits ethical and professional behavior. - Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency. - Computer Competency: Word processing, Spreadsheet, Email, PowerPoint and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired. - Must not be excluded from participation in any federal health care program. - Must not be included in CMS’ Preclusion List. Requirements - Experience in medical management, utilization review and case management in a managed care setting. - Knowledge of managed care products and strategies. - Ability to work within changing business environment and balance patient advocacy with business needs. - Experience with managing multiple projects in a fast-paced matrix environment. - Demonstrated ability to educate colleagues and staff members. - Successful experience and comfort with change management. - Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills. - Successful ability to assess complex issues, to determine and implement solutions, and resolve problems. - Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders. - Demonstrated sensitivity to culturally diverse situations, participants, and customers/members. - Service marketing, sales, and business acumen experience a plus. - Fluency in Spanish or other languages. Benefits - If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

Role Description A Medical Principal performs medical review and case management activities. The physician provides clinical insight to the organization through peer review, benefit review, consultation, and service to internal and external customers. He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims). This is an entry to mid-level position for a physician interested in a career in health care administration. - Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles. - Works to achieve quality outcomes for customers/members with a focus on service and cost. - Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills. - Balances customer/member needs with business needs while serving as a customer/member advocate at all times. - Participates in all levels of the Appeal process as appropriate and allowed by applicable regulatory agencies and accreditation organizations. - Participates in coverage guideline development, development and maintenance of medical management projects, initiatives and committees. - Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects. - Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes. - Improves health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information and the fostering of positive collegial relationships. - Demonstrates knowledge as a peer reviewer by applying current evidence-based guidelines, including novel treatments, to support high-quality clinical decision-making across medical and behavioral health conditions, diseases, treatments, and procedures. - Addresses customer service issues with mentoring and support from leadership staff. - Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff. - Achieves internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions. - Provides clinical insight and management support to other functional areas and matrix partners as needed or directed. Qualifications - Current unrestricted medical license in a US state or territory. - Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty. - Exhibits ethical and professional behavior. - Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency. - Computer Competency: Word processing, Spreadsheet, Email, PowerPoint and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired. - Must not be excluded from participation in any federal health care program. - Must not be included in CMS’ Preclusion List. Requirements - Experience in medical management, utilization review and case management in a managed care setting. - Knowledge of managed care products and strategies. - Ability to work within changing business environment and balance patient advocacy with business needs. - Experience with managing multiple projects in a fast-paced matrix environment. - Demonstrated ability to educate colleagues and staff members. - Successful experience and comfort with change management. - Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills. - Successful ability to assess complex issues, to determine and implement solutions, and resolve problems. - Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders. - Demonstrated sensitivity to culturally diverse situations, participants, and customers/members. - Service marketing, sales, and business acumen experience a plus. - Fluency in Spanish or other languages. - If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. Benefits - Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. - If you need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance. - The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. - Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.