[Remote] Medical Director - Medicaid N. Central 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, Medicaid, InsuranceIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, preferably including experience in inpatient and/or outpatient environments and/or related to care of a Medicaid population (TANF and expansion populations)
Current and ongoing Board Certification in an approved ABMS Medical Specialty
Current and unrestricted license in KY or willing to obtain by start date
Willingness to obtain additional license(s), as required (e.g., IN, OH, VA, WI)
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, case management, discharge planning and/or home health or post-acute services

Responsibilities

Rely on medical background to review health claims involving moderately complex to complex issues, requiring in-depth evaluation of variable factors
Use medical background, experience, and judgement to make determinations on whether requested services, level of care, and/or site of service should be authorized, within regulatory compliance using resources like national clinical guidelines, state policies, CMS policies, and clinical reference materials
Learn North Central region state Medicaid requirements (VA, KY, OH, IN, WI) and operationalize this knowledge in daily work
Perform computer-based review of moderately complex to complex clinical scenarios from outpatient, inpatient, or post-acute care environments, including review of submitted clinical records
Prioritize daily work and communicate decisions to internal associates, with possible participation in care management
Discuss with external physicians by phone to gather additional clinical information or discuss determinations through the Peer 2 Peer process, including conflict resolution when needed
Provide overview of coding practices, clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic testing, etc., within scope
Occasionally speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, including Humana processes, collaborative business relationships, value-based care, population health, or disease/care management
Provide medical interpretation and determinations on whether services provided by other healthcare professionals agree with national guidelines, state and CMS requirements, Humana policies, clinical standards, and contracts
Support and collaborate with team members, other departments, Humana colleagues, and the Regional VP Health Services
Perform daily work with minimal direction after training, but with team support, in a structured environment with expectations for consistency, independence in meeting departmental expectations, and compliance timelines

Skills

Key technologies and capabilities for this role

Medical ReviewClaims ReviewMedicaid RegulationsPeer to PeerClinical GuidelinesCMS PoliciesCare ManagementGrievance AppealsCoding PracticesClinical DocumentationDME ReviewGenetic Testing

Questions & Answers

Common questions about this position

What is the salary or compensation for the Medical Director role?

This information is not specified in the job description.

Is this Medical Director position remote or does it require office work?

This information is not specified in the job description.

What key skills are required for the Medical Director position?

The role requires a medical background, clinical judgment for reviewing claims and authorizing services, knowledge of North Central region Medicaid requirements (VA, KY, OH, IN, WI), regulatory compliance including CMS policies, and communication skills for peer-to-peer discussions and conflict resolution.

What is the work environment like at Humana for this Medical Director role?

The role involves working in a structured environment with expectations for consistency, collaboration with team members, departments, Humana colleagues, and the Regional VP Health Services, with minimal direction after training but ready support available.

What makes a strong candidate for the Medical Director - Medicaid N. Central role?

A strong candidate has a medical background, experience with complex clinical reviews, ability to operationalize regional Medicaid knowledge, enjoys structured environments with consistent decision-making, and excels in collaboration and independent work after training.

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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