Medical Director - Gulf South

The Medical Director will review health claims and make determinations on the authorization of requested services, level of care, and site of service based on medical background, national clinical guidelines, CMS policies, and Humana policies. Responsibilities include computer-based review of clinical scenarios, prioritization of work, communication of decisions, and potential participation in care management. The role involves discussing clinical information and determinations with external physicians, which may require conflict resolution. Some positions may oversee coding practices, clinical documentation, grievance and appeals processes, and outpatient services. The Medical Director will also collaborate with team members and other departments, support regional market priorities, and ensure compliance with regulatory requirements, working with minimal direction after training.