[Remote] Medical Director - Acute Rehab Team at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, preferably including experience in an inpatient environment and/or related to acute inpatient rehabilitation
Board Certified in an approved ABMS Medical Specialty with continued certification throughout employment
A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), if required
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, and acute inpatient rehabilitation
Preferred Qualifications
Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers
Utilization management experience in a medical management review organization, such as Medicare Advantage and managed Medicaid
Physical Medicine and Rehabilitation, Internal Medicine, Family Practice, Geriatrics, or Hospitalist background
Advanced degree such as an MBA, MHA, or MPH
The curiosity to learn, the flexibility to adapt and the courage to innovate

Responsibilities

Actively use medical background, experience, and judgement to make determinations on whether requested services, requested level of care, and/or requested site of service should be authorized, within a context of regulatory compliance
Learn Medicare and Medicare Advantage requirements, and operationalize this knowledge in daily work specifically for DSNP
Perform computer-based review of moderately complex to complex clinical scenarios, review all submitted clinical records, prioritize daily work, and communicate decisions to internal associates (predominantly from post-acute care environments)
Discuss with external physicians by phone to gather additional clinical information or discuss determinations, regularly requiring conflict resolution skills
Provide medical interpretation and determinations on whether acute inpatient rehabilitation authorization requests are in agreement with national guidelines, CMS requirements, Humana policies, and clinical standards
Support and collaborate with other team members, other departments, Humana colleagues, and clinical leadership
After training, perform daily work with minimal direction but with team support, in a structured environment with expectations for consistency
Exercise independence in meeting enterprise expectations and compliance timelines
Conduct Utilization Management of the care received by members in an assigned market, member population, or condition type
May engage in grievance and appeals reviews

Skills

Key technologies and capabilities for this role

Medical ReviewUtilization ManagementCMS PoliciesMedicare AdvantageDSNPPost-Acute CareInpatient RehabilitationClinical GuidelinesPhysician CommunicationConflict Resolution

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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