Neonatologist Reviewing Medical Director

This job posting is for a temporary contractor role as an employee of Atrium assigned to work at Humana.

Position Overview

The Neonatologist Reviewing Medical Director provides specialized clinical leadership for neonatal intensive care unit (NICU) utilization management and related clinical operations. This role applies neonatal expertise, regulatory requirements, and evidence-based guidelines to make timely, consistent medical-necessity determinations and support high-quality care for newborns and infants enrolled in Medicaid.

The Neonatologist Reviewing Medical Director evaluates complex NICU inpatient requests, including admission, continued-stay, level-of-care, transfer, and discharge-related reviews; collaborates with treating neonatologists and internal teams; and supports neonatal clinical operations across an assigned cluster of states.

Key Responsibilities

NICU Clinical Review and Decision-Making

• Apply board-certified neonatal expertise and clinical judgment to determine whether requested NICU admissions, continued stays, levels of care, transfers, and associated services meet applicable coverage and medical-necessity requirements.

• Review submitted maternal, delivery, newborn, and NICU clinical documentation and make timely determinations for medically complex neonates, premature infants, and critically ill newborns.

• Apply relevant federal and state Medicaid requirements, nationally recognized neonatal clinical guidelines, internal policies, coverage criteria, and other approved clinical resources when making determinations.

• Document clear, accurate, and clinically supported rationales that address the infant’s condition, gestational and postmenstrual age, respiratory and nutritional support, acuity, treatment needs, and readiness for a lower level of care or discharge, as applicable.

• Support NICU payment integrity by providing physician-level clinical review of DRG validation and level-of-care determinations, including assessment of whether billed diagnoses and NICU levels are supported by the clinical documentation and applicable Medicaid payment policies, and provide clinical input for complex or disputed cases.

• Prioritize assigned NICU reviews to meet regulatory, contractual, and operational timeliness requirements.

• Escalate complex, policy-sensitive, high-risk, or clinically ambiguous neonatal cases in accordance with established procedures.

Medicaid and Neonatal Clinical Operations

• Develop and maintain working knowledge of federal Medicaid requirements, assigned-state regulations, contractual obligations, and cluster-specific procedures applicable to neonatal and NICU services.

• Translate Medicaid requirements and neonatal clinical policies into consistent day-to-day NICU review decisions.

• Communicate determinations and relevant neonatal clinical information clearly to internal associates.

• Participate in neonatal quality, care-management, discharge-planning, and related clinical initiatives when assigned.

Physician and Stakeholder Collaboration

• Conduct peer-to-peer discussions with treating neonatologists, pediatric subspecialists, hospitalists, and other physicians to obtain additional clinical information, clarify the clinical rationale, and discuss determinations.

• Use effective communication and conflict-resolution skills during complex or disputed peer-to-peer discussions involving NICU care.

• Collaborate with physicians, NICU facilities, provider organizations, care-management teams, and community stakeholders to support regional priorities, neonatal outcomes, value-based care, population health, and effective care transitions.

• Build constructive working relationships with internal and external partners while maintaining appropriate clinical independence and regulatory compliance.

Team and Coverage Responsibilities

• Provide NICU review coverage and cross-coverage within the assigned cluster during planned absences, weekends, holidays, and periods of increased workload.

• Collaborate with medical directors, neonatal clinical teams, care-management teams, and operational partners to promote consistent and efficient NICU review practices.

• Demonstrate Humana’s values through ethical decision-making, respectful collaboration, and a commitment to addressing the clinical and social needs of newborns and their families.

Reporting Relationship

This position reports directly to the Director Physician Leadership.

Required Qualifications

• Doctor of Medicine or Doctor of Osteopathic Medicine degree.

• Board certification in Neonatal-Perinatal Medicine recognized by the American Board of Pediatrics.

• Active, unrestricted medical license in Oklahoma and/or South Carolina.

• Ability to obtain and maintain additional state medical licenses required for the role.

• At least five years of post-training clinical practice experience in Neonatal-Perinatal Medicine, including direct care of patients in a NICU setting.

• Experience conducting NICU utilization-management reviews in a health plan, independent review organization, hospital, or comparable payer or clinical environment.

• Ability to successfully complete all applicable credentialing requirements.

• No current sanctions imposed by a federal or state governmental authority.

Preferred Qualifications

• Experience working with Medicaid-enrolled newborns, families, providers, and stakeholders in a clinical or administrative setting.

• Experience with health-plan NICU case management, concurrent review, prior authorization, appeals, peer-to-peer review, or related clinical operations.

• Familiarity with National Committee for Quality Assurance accreditation standards and processes.

• Experience using clinical utilization-management platforms, including CGX and MHK, or comparable systems.

• Current participation in, or eligibility to participate in, the Interstate Medical Licensure Compact.

Licensure and Credentialing

The Neonatologist Reviewing Medical Director must maintain an active, unrestricted medical license in each state within the assigned cluster and obtain any additional licenses required to perform the responsibilities of the position.

Work Location

This is a virtual position. The Neonatologist Reviewing Medical Director should reside in one of the states within the assigned cluster, subject to applicable company requirements.

Internal Requisition Justification - Not for External Posting

This position will support specialized review of NICU admissions, continued stays, levels of care, transfers, and related neonatal services across the assigned cluster.