Director, Physician Leadership

Employment Type: Full time Location Type: (Not Specified) Salary: (Not Specified)

Position Overview

Humana, a $90 billion market leader in integrated healthcare, is seeking an accomplished healthcare leader for the newly-created role of Director, Physician Leadership. This is a key enterprise leadership position responsible for evolving Humana’s Utilization Management of medical review for over 5 million Medicare members. The role focuses on ensuring high-quality, appropriate, and consistent clinical decision-making to drive better health outcomes.

Requirements

• CMS Knowledge: Deep understanding of CMS regulations and policies specific to post-acute care authorizations, including long-term acute care hospital admissions, inpatient rehabilitation admissions, skilled facility admissions, and skilled facility continued stays.
• Collaboration: Passion for collaborating and partnering across the enterprise (e.g., Clinical Operations, Markets, Care Management, Analytics, Pharmacy) to develop and execute high-value strategies.
• Outcome-Driven: Driven by the sustainable improvement of health outcomes for vulnerable members.

Responsibilities

• Lead an operational team of Medical Directors, post-acute reviewing nurses, and reviewing support staff (indirect associates).
• Focus on post-acute reviews and ensure clinical decision-making aligns with internal policy and CMS regulations.
• Establish key metrics for operational success, 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 clear justifications for clinical decisions for Humana members.
  • Analytics and Measurement: Improving trend identification, highlighting areas for improvement in star measures, establishing tactics for advancing outcomes, and evaluating the impact of strategic initiatives. Synthesize data to inform clinically appropriate decisions and advance member health outcomes.
  • Outcomes: Characterizing impactful drivers of prior authorization and analyzing appeal rates with denials and overturns.
  • Internal Operations and Technology: Supporting efforts to enhance the efficiency of health plan operations (utilization management, 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 impact on health outcomes.
  • Innovation: Supporting health innovation, including increasing access to virtual and specialty care.
• Establish and maintain external relationships to stay informed about leading practices.

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. Humana is committed to advancing the employment experience and vitality of its 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.

Location: This position can be located anywhere within the lower 48 states.