Medical Director

Employment Type: Full-time

Position Overview

Become a part of our caring community and help us put health first. The Medical Director utilizes their medical background to review health claims. Work assignments involve moderately complex to complex issues where analysis requires an in-depth evaluation of variable factors. The Medical Director actively uses their medical background, experience, and judgment to make determinations on whether requested services, level of care, and site of service should be authorized. All work is performed within a context of regulatory compliance and is assisted by diverse resources, including national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise.

Medical Directors will learn Medicare and Medicare Advantage requirements and understand how to operationalize this knowledge in their daily work. The role involves computer-based review of clinical scenarios, review of submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and potential participation in care management. Clinical scenarios predominantly arise from inpatient or post-acute care environments. Regular discussions with external physicians by phone are required to gather additional clinical information or discuss determinations, which may sometimes require conflict resolution skills. Some roles may include an overview of coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment within their scope.

The Medical Director may also engage with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities. This may involve understanding Humana processes, focusing on collaborative business relationships, value-based care, population health, or disease or care management. Use your skills to make an impact.

Responsibilities

• Provide medical interpretation and determinations on whether services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts.
• Support and collaborate with other team members, departments, Humana colleagues, and the Regional VP Health Services.
• After completion of mentored training, perform daily work with minimal direction.
• Work effectively in a structured environment with expectations for consistency in thinking and authorship.
• Exercise independence in meeting departmental expectations and compliance timelines.

Required Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care experience post residency or fellowship, preferably including inpatient experience and/or care of Medicare-eligible populations (disabled or >65 years of age).
• Current and ongoing Board Certification in an approved ABMS Medical Specialty.
• A current and unrestricted license in at least one jurisdiction and willingness to obtain additional licenses if required.
• No current sanction from Federal or State Governmental organizations, and ability to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning, and/or home health or post-acute services such as inpatient rehabilitation.

Preferred Qualifications

• Specialties: Pulmonology, Sleep Medicine, Cardiology, General Surgery, Radiology, Interventional Radiology, and Genetics.
• Knowledge of the managed care industry, including Medicare Advantage, Managed Medicaid, and/or.