[Remote] Medical Director - OP Claims Mgmt at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience in an inpatient/outpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
Current and ongoing Board Certification in an approved ABMS Medical Specialty
Current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
No current sanction from Federal or State Governmental organizations, and able 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

Responsibilities

Actively use medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized at the Initial and Appeals/Disputes level, within a context of regulatory compliance
Learn Medicare, Medicaid, and Medicare Advantage requirements and operationalize this knowledge in daily work
Perform computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management
Have discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, which may require conflict resolution skills
Provide overview of coding practices and clinical documentation, disputes processes, and appeals processes, and outpatient services and equipment, within scope
Speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, including understanding of Humana processes, collaborative business relationships, value based care, population health, or disease or care management
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
Support and collaborate with other team members, other departments, Humana colleagues and the Regional VP Health Services
After completion of mentored training, perform daily work with minimal direction in a structured environment with expectations for consistency in thinking and authorship
Exercise independence in meeting departmental expectations, and meet compliance timelines

Skills

Key technologies and capabilities for this role

Medical ReviewUtilization ManagementMedicareMedicaidMedicare AdvantageClinical GuidelinesCMS PoliciesAppeals ProcessingCare ManagementConflict ResolutionCoding PracticesClinical DocumentationPopulation HealthValue Based Care

Questions & Answers

Common questions about this position

What qualifications are required for the Medical Director role?

Candidates must have an MD or DO degree, 5+ years of direct clinical patient care experience post residency or fellowship (preferably in inpatient/outpatient settings or with Medicare populations), and current and ongoing Board Certification from an approved ABMS organization.

Is this a remote position or does it require office work?

This information is not specified in the job description.

What is the salary or compensation for this position?

This information is not specified in the job description.

What is the work environment like at Humana for this role?

The role involves working in a structured environment with expectations for consistency, minimal direction after training, collaboration with team members and departments, and independence in meeting departmental expectations while adhering to compliance timelines.

What makes a strong candidate for the Medical Director position?

A strong candidate has direct clinical experience in inpatient/outpatient settings or with Medicare populations, enjoys structured work with consistency, excels in collaboration and independent decision-making, and can handle phone discussions with external physicians including conflict resolution.

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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