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 fundamentals of CMS Medicare Guidance for following and reviewing home health, SNF, DME, dual Medicare/Medicaid, and Waiver requests. The Medical Director 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.

The Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. All work occurs within a context of regulatory compliance and is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise.

Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. The Medical Director works in a structured environment with expectations for consistency in thinking, authorship, meeting departmental expectations, and compliance timelines. Use your skills to make an impact.

Responsibilities

• Conducts clinical case reviews of requests received from members of the Medicare population and reports to the Lead Medical Director.
• Identifies medical management operational improvements, including those within the medical director area.
• Participates in call rotation, which may include weekend coverage.
• Develops collaborative relationships with the Team and key partners within the Medicare Line of Business.
• Supports Home Solutions as needed.
• Performs other activities as assigned by the managing Medical Director.

Requirements

• MD or DO degree.
• 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 licenses as required for various states in the region of assignment.
• 5+ years of direct clinical patient care experience post residency or fellowship.
• No sanctions from Federal or State Governmental organizations.
• 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.

Preferred Qualifications

• Experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age).
• Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care or hospital-based clinical specialists.
• Ability to function in a dynamic, fast-paced environment.
• Commitment to a culture of innovation.
• Passionate about contributing to an organization’s focus on consistency in outcomes, consumer experiences, and a highly engaged team culture.
• Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual.

Compensation and Benefits

• Pay Range: $223,800 - $313,100 per year
• This job is eligible for a bonus incentive plan based on company and/or individual performance.
• Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits.

Travel

While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Location Type:

• Remote