Medical Director - Mid West Region

The Medical Director will actively use their medical background to determine if requested services, level of care, and site of service are authorized, ensuring compliance with regulatory requirements, national clinical guidelines, CMS policies, and Humana policies. This role involves computer-based review of clinical scenarios, review of clinical records, prioritization of work, communication of decisions, and potential participation in care management, primarily focusing on inpatient or post-acute care environments. The Medical Director will also engage in discussions with external physicians to gather information or discuss determinations, potentially involving conflict resolution, and may oversee coding practices, clinical documentation, grievance and appeals processes, and outpatient services. Additionally, they will collaborate with team members and departments, support market-wide objectives, and maintain consistency in thinking and authorship while exercising independence in meeting departmental expectations and compliance timelines.