Humana

Medical Director - OneHome

San Antonio, Texas, United States

Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries

Requirements

Candidates must possess an MD or DO degree with current and ongoing board certification in an approved ABMS Medical Specialty. A current and unrestricted medical license in at least one jurisdiction is required, with willingness to obtain licenses in other states as needed. The role demands a minimum of 5 years of direct clinical patient care experience post-residency or fellowship and requires no sanctions from Federal or State Governmental organizations. Applicants must be able to pass credentialing requirements and demonstrate excellent verbal and written communication skills, along with strong analytic and interpretive abilities. Preferred qualifications include experience in an inpatient setting or with the Medicare population, knowledge of national guidelines like NCD/LCD, MCG®, or InterQual, and the ability to thrive in a fast-paced, dynamic environment.

Responsibilities

The Medical Director will review home health, SNF, DME, and dual Medicare/Medicaid requests based on CMS Medicare Guidance. They will provide medical interpretation and determine if services align with national guidelines, CMS requirements, Humana policies, clinical standards, and contracts. Responsibilities include conducting clinical case reviews for Medicare members, reporting to the Lead Medical Director, and identifying operational improvements within medical management. The role also involves participating in call rotations, potentially including weekend coverage, developing collaborative relationships with teams and partners, and supporting Home Solutions as needed. Additionally, the Medical Director will create content for and participate in educational activities and may travel occasionally for training or meetings.

Skills

Medical Director
CMS Medicare Guidance
Home Health
SNF
DME
Medicare/Medicaid
Waiver requests
Clinical guidelines
CMS requirements
Humana policies
Clinical standards
Medicare Advantage
Regulatory compliance
MD or DO degree
Board certification
Medical specialty
Medical license
Clinical patient care
Communication skills
Analytic skills
Interpretive 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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