Medical Director - Florida

The Medical Director will provide medical interpretation and make determinations on whether services align with national guidelines, CMS requirements, Humana policies, clinical standards, and contracts. They will review health claims, analyze clinical scenarios, and evaluate variable factors to authorize requested services, level of care, and site of service. Responsibilities include learning and operationalizing Medicare and Medicare Advantage requirements, reviewing clinical records, prioritizing work, communicating decisions, potentially participating in care management, and discussing determinations with external physicians, which may involve conflict resolution. Some roles may involve overseeing coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment. The Medical Director will also support regional market priorities, collaborate with team members and departments, and uphold Humana values and mission.