Responsibilities

The Medical Director will provide medical interpretation and determinations regarding the appropriateness of services provided by other healthcare professionals, ensuring alignment with national guidelines, state and CMS requirements, Humana policies, and clinical standards. They will also participate in computer-based review of clinical scenarios, review of submitted clinical records, prioritize daily work, communicate decisions to internal associates, and engage in discussions with external physicians to gather clinical information. Additionally, the Medical Director will contribute to reviews for DME, genetic testing, and other relevant areas, and may participate in care management and provide an overview of coding practices and clinical documentation.