Medical Director - Claims Management

The Medical Director will utilize their medical background to determine authorization for requested services, level of care, and site of service, ensuring compliance with regulatory requirements, national clinical guidelines, CMS and state policies, and internal standards. Responsibilities include reviewing clinical scenarios and records, prioritizing daily tasks, communicating decisions, and potentially participating in care management. The role may involve discussions with external physicians, reviewing coding practices, clinical documentation, dispute resolution, and supporting regional market priorities through collaboration with external physicians, groups, and facilities. The Medical Director will support Humana values and collaborate with team members and other departments, working with minimal direction after training and demonstrating consistency in thinking and authorship.