Medical Director -National UM Team - Remote at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, preferably including inpatient experience and/or Medicare population care
Current and ongoing Board Certification in an approved ABMS Medical Specialty
Current and unrestricted license in at least one jurisdiction
No current sanction from Federal or State Governmental organizations
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills

Responsibilities

Provides medical interpretation and determinations regarding healthcare services
Reviews health claims for medical necessity
Makes determinations whether requested services, level of care, and/or site of service should be authorized
Performs computer-based review of clinical scenarios
Reviews all submitted clinical records
Prioritizes daily work
Communicates decisions to internal associates
Participates in care management (possible)
Discusses determinations with external physicians
May oversee coding practices and clinical documentation
May participate in grievance and appeals processes
May review outpatient services and equipment
May speak with contracted external physicians, physician groups, facilities, or community groups
Supports market-wide objectives and community relations

Skills

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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