Medical Director - National Medicare Team

San Antonio, Texas, United States

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Not SpecifiedCompensation

Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

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 or Medicare-related population care. A current and unrestricted license, ongoing Board Certification, and no federal or state sanctions are required. Preferred qualifications include knowledge of the managed care industry, utilization management experience, and familiarity with national guidelines.

Responsibilities

The Medical Director will review preauthorization requests for services, making determinations based on medical background, national clinical guidelines, CMS policies, and Humana policies. Responsibilities include analyzing clinical scenarios, communicating decisions, potentially participating in care management, and discussing determinations with external physicians. Some roles may involve overseeing coding practices, documentation, grievance processes, and outpatient services. The role also entails supporting team members, collaborating with departments, and potentially engaging with external groups to support market priorities.

Skills

Medical Review

Preauthorization

Clinical Guidelines

CMS Policies

Medicare

Medicare Advantage

Inpatient Care

Post-Acute Care

Physician Communication

Conflict Resolution

Coding Practices

Clinical Documentation

Grievance and Appeals

Outpatient Services

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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