[Remote] Medical Director - National UM Team (Inpatient) 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
4 x 10h schedule (Fri, Sat, Sun, Mon)
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 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, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation

Responsibilities

Rely on medical background to review health claims involving moderately complex to complex issues
Use medical background, experience, and judgement to make determinations on authorization of requested services, level of care, and/or site of service
Ensure all work complies with regulatory requirements, using resources like national clinical guidelines, CMS policies, clinical reference materials, internal teaching conferences, and other expertise
Learn and operationalize Medicare and Medicare Advantage requirements in daily work
Perform computer-based review of moderately complex to complex clinical scenarios from inpatient or post-acute care environments, including review of submitted clinical records
Prioritize daily work and communicate decisions to internal associates
Participate in care management as needed
Discuss with external physicians by phone to gather additional clinical information or discuss determinations, including conflict resolution
Provide overview of coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment within scope
Speak 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/care management
Provide medical interpretation and determinations on whether services by other healthcare professionals agree with national guidelines, CMS requirements, Humana policies, clinical standards, and contracts (in some cases)
Support and collaborate with team members, other departments, Humana colleagues, and Regional VP Health Services
Perform daily work with minimal direction after mentored training, in a structured environment with consistency in thinking and authorship
Exercise independence in meeting departmental expectations and compliance timelines

Skills

Medical Review

Utilization Management

Medicare

Medicare Advantage

Claims Review

Clinical Guidelines

CMS Policies

Inpatient Care

Post-Acute Care

Conflict Resolution

Coding Practices

Clinical Documentation

Grievance and Appeals

Physician Communication

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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