Director, Physician Leadership

Employment Type: Full time Location Type: Any within the lower 48 states

Position Overview

Humana, a $90 billion market leader in integrated healthcare, is seeking an accomplished healthcare physician leader for the newly-created role of Director, Physician Leadership. This is a key enterprise leadership position responsible for evolving Humana’s Utilization Management (UM) medical review processes, with a focus on our 5+ million Medicare members. The role aims to facilitate the delivery of high-quality, appropriate, and consistent clinical decision-making to ensure optimal outcomes and drive better health outcomes for our members.

Requirements

• Well-versed in CMS knowledge of outpatient, inpatient, and appeal criteria, including regulations and policies.
• Passionate about collaborating and partnering across the enterprise (e.g., Clinical Operations, Markets, Care Management, Analytics, Pharmacy) to develop and execute high-value strategies.
• Driven by sustainably improving health outcomes for vulnerable members.

Responsibilities

• Lead an operational team of Medical Directors performing utilization management for inpatient authorizations.
• Train the Medical Director team to assist and facilitate new hires and remediation of Medical Directors performing Medicare UM processes.
• Serve as the liaison for the Medicare Market Provider Experience Clinician.
• Establish key metrics of success for the team and operational progress, encompassing quality, access, and financial metrics (e.g., medical trend reduction, administrative costs).
• Collaborate with enterprise partners to develop, articulate, implement, evaluate, and refine strategic initiatives addressing:
  • Access: Ensuring fair and consistent authorization reviews, appeals processes, and justification for clinical decisions for Humana members.
  • Analytics and Measurement: Improving the identification of trends, highlighting areas for improvement in star measures, establishing tactics for advancing outcomes, and evaluating the impact of strategic initiatives. Synthesizing data to inform clinically appropriate decisions and advance member health outcomes.
  • Outcomes: Characterizing impactable drivers of prior authorization and analyzing appeals rates, including denials and overturns. Delivering consistent medical director decision-making.
  • Internal Operations and Technology: Supporting efforts to improve the efficiency of health plan operations (UM and provider clinical contracting) to reduce friction for members, providers, and associates.
  • External Partnerships: Exploring, evaluating, and implementing novel partnerships with national and community-based organizations to expand Humana’s ability to impact health outcomes.
  • Innovation: Supporting health innovation, including increasing access to virtual and specialty care.

Company Information

Humana is a $90 billion (Fortune 40) market leader in integrated healthcare with a clearly defined purpose to help people achieve lifelong well-being. As a company focused on the health and well-being of the people we serve, Humana is committed to advancing the employment experience and vitality of the associate community. Through offerings anchored in a whole-person view of human well-being, Humana embraces a focus on stimulating positive individual and population changes while nurturing a sense of security, enabling people to live life fully and be their most productive.