Medical Director - National Medicare

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. They will analyze moderately complex to complex clinical scenarios, primarily from inpatient or post-acute care settings, reviewing submitted clinical records and prioritizing daily work. Responsibilities include communicating decisions to internal associates, potentially participating in care management, and engaging with external physicians via phone to gather clinical information or discuss determinations, which may involve conflict resolution. 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 Humana processes, collaborative business relationships, value-based care, population health, or disease/care management. After mentored training, daily work is performed with minimal direction, requiring independence in meeting departmental expectations and compliance timelines.