[Remote] Medical Director - National UM 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 inpatient environment and/or care of 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 licenses 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 with prior experience working in a team environment
Weekend work required one weekend per month with compensated days off during the work week
Preferred Qualifications
Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/Integrated Delivery Systems, health insurance, or other healthcare providers
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
Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Medicine

Responsibilities

Actively use medical background, experience, and judgement to make determinations on whether requested services, level of care, and/or site of service should be authorized, within regulatory compliance using resources like national clinical guidelines, CMS policies, clinical reference materials, internal teaching conferences, and other sources
Learn Medicare and Medicare Advantage requirements and operationalize this knowledge in daily work
Review all submitted medical records, synthesize complex hospital-based clinical scenarios, and provide expert decisioning on requested services
Have regular discussions with external providers by phone to gather additional clinical information and discuss determinations
Understand Humana processes with a focus on collaborative professional relationships
Provide medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts
After training, perform daily work with minimal direction but with team support, exercising independence in meeting departmental expectations and compliance timelines
Conduct comprehensive, timely, and compliant medical necessity reviews for inpatient services
Maintain accountability for productivity, quality, and compliance metrics
Communicate determinations clearly both verbally and in writing
Demonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practices

Skills

Key technologies and capabilities for this role

Medical ReviewUtilization ManagementMedicareCMS PoliciesClinical Decision MakingRegulatory ComplianceMedical Records ReviewProvider Communication

Questions & Answers

Common questions about this position

What qualifications are required for the Medical Director role?

Candidates must have an MD or DO degree, 5+ years of direct clinical patient care experience post residency or fellowship (preferably in inpatient or Medicare populations), and current and ongoing Board Certification.

Is weekend work required for this position?

Yes, weekend work is required one weekend per month, with compensated days off during the work week.

What is the company culture like for Medical Directors at Humana?

The role involves working in a team-based environment with a structured approach, expectations for consistency, collaborative professional relationships, and support from team members, while upholding Humana values with high integrity and professionalism.

What does a strong candidate for this Medical Director position look like?

A strong candidate has the required medical qualifications, enjoys team-based and structured environments, demonstrates integrity, professionalism, resourcefulness, adaptability, and a willingness to learn evolving workflows.

What is the salary or compensation for this role?

This information is not specified in the job description.

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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