Director, Physician Leadership – Medical Directors + MD trainer

San Antonio, Texas, United States

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Not SpecifiedCompensation

Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Candidates must be physicians with experience in healthcare leadership and utilization management, particularly for Medicare members. A strong understanding of CMS knowledge, including outpatient, inpatient, and appeal criteria, regulations, and policies is essential. The role requires a passion for collaboration across various enterprise departments and a drive to improve health outcomes for vulnerable populations.

Responsibilities

The Director, Physician Leadership will lead a team of Medical Directors in the utilization management of medical reviews, focusing on Medicare members. Responsibilities include ensuring high-quality clinical decision-making aligned with internal policies and CMS regulations, establishing key performance metrics for quality, access, and financial outcomes, and collaborating with enterprise partners to develop and implement strategic initiatives. This includes improving access to care, leveraging analytics for better health outcomes, refining internal operations and technology for efficiency, exploring external partnerships, and supporting health innovation.

Skills

Physician Leadership

Utilization Management

Medical Review

Medicare

CMS

Outpatient Criteria

Inpatient Criteria

Appeal Criteria

Clinical Decision Making

Healthcare

Leadership

Training

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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