[Remote] Medical Director - National Outpatient Medicare Team at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
Current and ongoing Board Certification in an approved ABMS Medical Specialty
Current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills
The curiosity to learn, the flexibility to adapt and the courage to innovate
Preferred Qualifications
Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid
Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance
Experience with national guidelines such as MCG® or InterQual
Advanced degree such as an MBA, MHA, M

Responsibilities

Reviews preauthorization requests for services using medical background, experience, and judgement to determine if requested services, level of care, and/or site of service should be authorized
Conducts computer-based review of moderately complex to complex clinical scenarios, including review of all submitted clinical records
Prioritizes daily work and communicates decisions to internal associates
Participates in care management as needed
Has discussions with external physicians by phone to gather additional clinical information or discuss determinations, including conflict resolution
Provides overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment (within scope)
Speaks with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, including Humana processes, collaborative business relationships, value-based care, population health, or disease or care management
Provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts
Supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services
Performs daily work with minimal direction after completion of mentored training
Exercises independence in meeting departmental expectations and meets compliance timelines

Skills

Key technologies and capabilities for this role

Medical ReviewPreauthorizationMedicareMedicare AdvantageClinical GuidelinesCMS PoliciesRegulatory ComplianceCare ManagementPhysician CommunicationConflict ResolutionClinical DocumentationGrievance and Appeals

Questions & Answers

Common questions about this position

What are the required qualifications for the Medical Director role?

Candidates must have an MD or DO degree and 5+ years of direct clinical patient care experience post residency or fellowship.

Is this a remote position or does it require office work?

This information is not specified in the job description.

What is the salary or compensation for this position?

This information is not specified in the job description.

What does the work environment look like for this role?

The role involves working in a structured environment with expectations for consistency in thinking and authorship, minimal direction after training, and collaboration with team members, departments, and Humana colleagues.

What makes a strong candidate for this Medical Director position?

A strong candidate has an MD or DO, 5+ years of post-residency clinical experience, enjoys structured environments with consistent decision-making, and can collaborate effectively while exercising independent judgment in complex clinical reviews.

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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