Medical Director - Mid West Region

Position Overview

• Location Type: Remote
• Employment Type: Full Time
• Salary: Not specified

This role offers the opportunity to join a caring community and contribute to a health-focused environment. The Medical Director will utilize their medical expertise and judgment to determine the appropriate authorization of requested services, levels of care, and sites of service, ensuring all work adheres to regulatory compliance and utilizes available resources like national clinical guidelines and CMS policies. The position involves computer-based review of complex clinical scenarios, record review, prioritization of daily tasks, communication of decisions, and potential participation in care management. It may also include discussions with external physicians, understanding of coding practices, and support for regional market priorities.

Requirements

• Medical background and experience
• Strong understanding of national guidelines and CMS requirements
• Ability to interpret clinical scenarios
• Communication and collaboration skills
• Conflict resolution skills (potentially)
• Familiarity with coding practices and clinical documentation (potentially)
• Understanding of Humana processes and value-based care (potentially)

Responsibilities

• Provides medical interpretation and determinations regarding services provided by other healthcare professionals.
• Ensures services align with national guidelines, CMS requirements, Humana policies, and clinical standards.
• Collaborates with other team members, departments, and Humana colleagues.
• Participates in structured and mentored training, transitioning to independent work with minimal direction.
• Supports assigned work with respect to market-wide objectives (e.g., Bold Goal) and community relations.
• Discusses clinical information with external physicians via phone.
• May provide an overview of coding practices and clinical documentation.
• May support grievance and appeals processes and outpatient services and equipment.
• May engage with contracted external physicians, physician groups, or facilities to support regional market priorities.

Application Instructions

• Not specified in the provided text. (Further information would be needed to provide specific instructions.)