Medicaid Analyst Jobs in Raleigh, NC (NOW HIRING)

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 The Behavioral Health Medical Director is responsible for behavioral health care strategies and/or operations. You will work assignments involving moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities:

• Use your medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and assisted by diverse resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources

• Learn Medicaid requirements and understand how to operationalize this knowledge in your daily work assigned cluster

• Work 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, with clinical scenarios arising from outpatient or inpatient environments

• 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 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 and a focus on collaborative business relationships, values-based care, population health, or disease or care management

• Supports Humana values including working collaboratively on a team throughout all activities

• Flows to work as needed within cluster as needed for vacations, weekends and holidays coverage

Reporting Relationship:

This position reports directly to the Lead Behavioral Health Medical Director.

Use your skills to make an impact
 

Requirements: 

• Doctor of Medicine or Doctor of Osteopathy 

• Board-certified in an ABMS recognized specialty of Psychiatry

• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required

• At least five years of experience post-training providing clinical services 

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

• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements

• SSN request is a reference check task that scans for duplicate profiles in our Workday ATS that will be requested at the offer stage

Preferred:

• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting

• Experience with accreditation process (NCQA)

• Experience with CGX and MHK

• Has licensure through the Interstate Medical Licensure Compact

• Has a Louisiana medical license

• Has experience with application of MCG and ASAM criteria

License/Credential Requirement

Physician with an active, unencumbered license in at least one of the states that are part of the specific cluster (Louisiana, Oklahoma, Indiana, Ohio, Florida, Virginia, Kentucky).

Location: This role is based virtually in one of the states of the specific cluster.

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.

 

$223,800 - $313,100 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. Application Deadline: 12-20-2026
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.