[Remote] Medical Director - National UM Team (weekends) 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 experience in an inpatient environment and/or care of a Medicare type population
Current and ongoing Board Certification in an approved ABMS Medical Specialty
Current and unrestricted license in at least one jurisdiction and willingness to obtain additional licenses if required
No current sanction from Federal or State Governmental organizations, and ability to pass credentialing requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills, with prior experience working in a team environment

Responsibilities

Actively use medical background, experience, and judgement to make determinations whether requested services, level of care, and/or site of service should be authorized
Review submitted medical records and synthesize complex hospital-based clinical scenarios
Provide expert decisioning on the 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 contracts
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
Work every other weekend with compensated days off during the work week

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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