Medical Director - National Medicare Team

The Medical Director will review preauthorization requests for services, applying medical background, experience, and judgment to determine authorization based on national clinical guidelines, CMS policies, and Humana policies. Responsibilities include computer-based review of clinical scenarios, evaluation of submitted records, prioritization of daily tasks, communication of decisions, and potential participation in care management. The role involves discussions with external physicians to gather information or discuss determinations, sometimes requiring conflict resolution. Some positions may also involve overseeing coding practices, clinical documentation, grievance and appeals processes, and outpatient services. Additionally, the Medical Director may engage with external physicians, groups, and facilities to support regional market priorities, focusing on collaborative relationships, value-based care, population health, or disease/care management.