Medical Director (Value Based Care)
Pair TeamSalary not specified
- Full Time
- Senior (5 to 8 years)
Not SpecifiedCompensation
Junior (1 to 2 years)Experience Level
Full TimeJob Type
UnknownVisa
HealthcareIndustries
Requirements
Candidates should possess a Medical Degree (MD or DO) and hold a valid medical license in the state of Illinois. A Master's degree in Public Health or a related field is preferred, along with at least 7 years of clinical experience, including significant leadership experience in a healthcare setting. Strong knowledge of Medicare and Medicare Advantage requirements, CMS policies, and national clinical guidelines is essential, as is the ability to interpret and apply these regulations. Experience with care management, population health, and value-based care models is also desired.
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, CMS requirements, Humana policies, and clinical standards. They will collaborate with other team members, departments, and external stakeholders to support regional market priorities and Humana’s Bold Goal mission. The Medical Director will participate in care management activities, review clinical records, and communicate decisions to internal associates and external physicians. They will also support Humana values, and may provide an overview of coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment.
Skills
Medical expertise
Understanding of national guidelines
CMS requirements
Clinical scenario interpretation
Communication skills
Collaboration skills
Conflict resolution
Coding practices
Clinical documentation
Regulatory compliance
Health policy understanding
Care management
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.
Key Metrics
Louisville, KentuckyHeadquarters
1961Year Founded
IPOCompany Stage
Social Impact, HealthcareIndustries
10,001+Employees