Medical Director - National Medicare

The Medical Director will review health claims, utilizing 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, analysis of submitted records, prioritization of daily work, communication of decisions, and potential participation in care management, predominantly in inpatient or post-acute care settings. They will also engage in discussions with external physicians to gather clinical information or discuss determinations, potentially involving conflict resolution. Some roles may involve oversight of coding practices, clinical documentation, grievance and appeals processes, and outpatient services. Additionally, the Medical Director may interact with external physicians, groups, or facilities to support regional market priorities, focusing on collaborative relationships, value-based care, population health, or disease/care management. The role requires providing medical interpretation and determinations that align with clinical standards and contracts, supporting and collaborating with team members and other departments, and working with minimal direction after mentored training in a structured environment with a focus on consistency and compliance.