Medical Director (Value Based Care)
Pair TeamSalary not specified
- Full Time
- Senior (5 to 8 years)
Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, Managed Care, MedicareIndustries
Requirements
Candidates must possess a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree, along with a minimum of five years of direct clinical patient care experience following residency or fellowship, ideally including inpatient experience and experience with Medicare-eligible populations (disabled or over 65 years of age). They must hold current and ongoing board certification in an approved medical specialty, a current and unrestricted license in at least one jurisdiction, and be free from any current sanctions from federal or state governmental organizations. Strong analytical and interpretation skills, demonstrated through experience in quality management, utilization management, case management, discharge planning, or home health/post-acute services, are also required.
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 actively collaborate with team members, departments, and the Regional VP Health Services, performing daily work with minimal direction after completing mentored training. The Medical Director will review clinical records, prioritize work, communicate decisions to internal associates, and potentially participate in care management. They will also engage in discussions with external physicians, support regional market priorities, and contribute to collaborative business relationships focused on value-based care and population health, while potentially overseeing coding practices, clinical documentation, grievance and appeals processes, and outpatient services.
Skills
Medical background
Clinical review
Regulatory compliance
CMS policies
Clinical guidelines
Care management
Communication
Conflict resolution
Coding practices
Clinical documentation
Grievance and appeals processes
Outpatient services
Medicare and Medicare Advantage knowledge
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