Humana

Medical Director - National Medicare

San Antonio, Texas, United States

Not SpecifiedCompensation
Expert & Leadership (9+ years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries

Requirements

Candidates must possess an MD or DO degree and have at least 5 years of direct clinical patient care experience post-residency or fellowship, preferably including inpatient experience or care for Medicare-eligible populations. A current and ongoing Board Certification in an approved ABMS Medical Specialty is required, along with an unrestricted license in at least one jurisdiction and the willingness to obtain additional licenses. Candidates must not have current sanctions from federal or state governmental organizations and must pass credentialing requirements. Excellent verbal and written communication skills, along with demonstrated analytic and interpretation skills from prior experience in quality management, utilization management, case management, discharge planning, or post-acute services, are also necessary. Preferred qualifications include specialties such as pulmonology, sleep medicine, cardiology, general surgery, radiology, interventional radiology, and genetics, as well as knowledge of the managed care industry including Medicare Advantage and Managed Medicaid.

Responsibilities

The Medical Director will review health claims, using their medical background and judgment to determine authorization for requested services, level of care, and site of service, ensuring compliance with regulatory requirements, national clinical guidelines, CMS policies, and Humana policies. Responsibilities include computer-based review of clinical scenarios, evaluation of submitted clinical records, prioritization of daily work, communication of decisions, and potential participation in care management. The role involves discussions with external physicians to gather clinical information or discuss determinations, which may require conflict resolution skills. Some roles may involve overseeing coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment. The Medical Director may also engage with external physicians, groups, and facilities to support regional market priorities, focusing on collaborative business relationships, value-based care, population health, or disease/care management.

Skills

Medical Claims Review
Clinical Guidelines
CMS Policies
Medicare
Medicare Advantage
Clinical Documentation
Coding Practices
Grievance and Appeals
Conflict Resolution
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.

Louisville, KentuckyHeadquarters
1961Year Founded
IPOCompany Stage
Social Impact, HealthcareIndustries
10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.
Rising medical costs and tightening Medicare reimbursements may strain financial performance.
Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.
The company emphasizes inclusivity, offering free language interpreter services for accessibility.
Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.
The company is the first insurer to cover TMS therapy for adolescent depression.
Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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