[Remote] Medical Director - OneHome at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicare, InsuranceIndustries

Requirements

MD or DO degree
Current and ongoing board certification through an approved ABMS or AOABPS Medical Specialty (NBPAS certification not accepted)
Current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment
5+ years of direct clinical patient care experience post residency or fellowship
No sanctions from Federal or State Governmental organizations
The ability to pass credentialing requirements
Excellent verbal and written communication skills with analytic and interpretative skills
Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution

Responsibilities

Follow and review home health, SNF, DME, dual Medicare/Medicaid and Waiver requests per CMS Medicare Guidance
Provide medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts
Provide medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards
Learn Medicare and Medicare Advantage requirements, and understand how to operationalize this knowledge in daily work
Work in a structured environment with expectations for consistency in thinking, authorship, meeting departmental expectations, and compliance timelines
Conduct clinical case reviews of requests received by members of the Medicare population and report to the Lead Medical Director
Identify medical management operational improvements, including those within the medical director area
Participate in call rotation which includes weekend coverage
Develop collaborative relationships with Team and key partners within the Medicare Line of Business
Support Home Solutions as needed
Other activities as assigned by the managing Medical Director

Skills

Key technologies and capabilities for this role

MDDOBoard CertifiedABMSAOABPSMedical LicenseClinical Patient CareCMS Medicare GuidanceHome HealthSNFDMEMedicare AdvantageMedical ReviewRegulatory Compliance

Questions & Answers

Common questions about this position

What are the required qualifications for the Medical Director role?

Candidates must have an MD or DO degree, current board certification through ABMS or AOABPS (NBPAS not accepted), a current unrestricted license in at least one jurisdiction with willingness to obtain more, 5+ years of direct clinical patient care post-residency, no sanctions, and excellent communication and analytic skills.

What preferred qualifications are there for this position?

Preferred experience includes inpatient care or with Medicare populations, specialties like Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, ability to work in a fast-paced environment, commitment to innovation, and knowledge of guidelines like NCD/LCD, MCG, or InterQual.

Is this a remote position or does it require a specific location?

This information is not specified in the job description.

What is the salary or compensation for the Medical Director role?

This information is not specified in the job description.

What does the company culture emphasize for this role?

The role emphasizes a culture of innovation, consistency in outcomes, consumer experiences, and a highly engaged team culture.

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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