Medical Director

Employment Type: Full-time

Position Overview

Become a part of our caring community and help us put health first. The Medical Director relies on their medical background to review health claims. This role involves moderately complex to complex issues where analysis requires an in-depth evaluation of variable factors. The Medical Director provides medical interpretation and decisions regarding the appropriateness of services provided by other healthcare professionals, ensuring compliance with review policies, procedures, and performance standards. This position begins to influence department strategy and makes decisions on moderately complex to complex issues regarding technical approaches for project components, working without direction. Exercises considerable latitude in determining objectives and approaches to assignments. Use your skills to make an impact.

Responsibilities

• Provides medical interpretation and determinations on 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, and Humana colleagues.
• After completion of mentored training, daily work is performed with minimal direction.
• Enjoys working in a structured environment with expectations for consistency in thinking and authorship.
• Exercises independence in meeting departmental expectations and meets compliance timelines.
• Conducts Utilization Management of care received by members in an assigned market, member population, or condition type.
• May engage in grievance and appeals reviews.
• May participate on project teams or organizational committees.

Required Qualifications

• 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 the care of a Medicare type population (disabled or >65 years of age).
• Current and ongoing Board Certification in an approved ABMS Medical Specialty.
• A 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 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.

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, other healthcare providers, clinical group practice management.
• 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.
• Clinical specialists in Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine.
• Advanced degree such as an MBA, MHA, MPH.
• Exposure to Public Health, Population Health, analytics, and use of business metrics.
• Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.
• Curiosity to learn, flexibility to adapt, and courage to innovate.

Additional Information

• Typically reports to a Lead or Corporate Medical Director, depending on the size of the region or line of business.
• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
• Scheduled Weekly Hours: 40
• Pay Range: [Pay range not specified in original description]

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