Medical Director-Payment Integrity

Position Overview

• Location Type:
• Job Type: Full time
• Salary:

This role involves utilizing medical background, experience, and judgment to determine if requested services, level of care, and site of service should be authorized at the Inpatient level. Work is performed within a context of regulatory compliance, utilizing resources such as national clinical guidelines, CMS policies, and clinical reference materials. The Medical Director will learn and apply Medicare, Medicaid, and Medicare Advantage requirements.

The work includes computer-based review of clinical scenarios, primarily from inpatient or post-acute care environments, reviewing submitted clinical records, prioritizing daily tasks, and communicating decisions. Peer-to-peer discussions with external providers may occur. Some roles may involve an overview of coding practices, clinical documentation, dispute/grievance and appeals processes, and outpatient services and equipment. Medical Directors support Humana's values and mission.

Requirements

• MD or DO degree
• 5+ years of direct clinical patient care experience post residency or fellowship, preferably including inpatient experience and/or care of Medicare-eligible populations.
• Current and ongoing Board Certification in an approved ABMS Medical Specialty.
• A current and unrestricted license in at least one jurisdiction; willingness to obtain additional licenses if required.
• No current sanctions from Federal or State Governmental organizations and ability to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills.
• Prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning, and/or home health or post-acute services.

Responsibilities

• Provide medical interpretation and determinations regarding services provided by other healthcare professionals, ensuring agreement with national guidelines, CMS requirements, Humana policies, and clinical standards.
• Support and collaborate with other team members, departments, and Humana colleagues.
• Perform daily work with minimal direction after completing mentored training.
• Work effectively in a structured environment with expectations for consistency in thinking and authorship.
• Exercise independence in meeting departmental expectations and compliance timelines.
• Support assigned work concerning market-wide objectives and community relations.

Preferred Qualifications

• Knowledge of the managed care industry (Medicare Advantage, Managed Medicaid, Commercial products), medical management organizations, hospitals/Integrated Delivery Systems, health insurance, other healthcare providers, or clinical group practice management.
• Utilization management experience in a medical management review organization.
• Experience with national guidelines such as MCG® or InterQual.
• Clinical specialization in Internal Medicine, Family Practice, Geriatrics, Hospitalist, or Emergency Medicine.
• Advanced degree such as MBA, MHA, or MPH.
• Exposure to Public Health, Population Health, analytics, and business metrics.
• Curiosity to learn.