Medical Director- South Central

The Medical Director will actively use their medical background to determine if requested services, level of care, and site of service meet regulatory compliance standards, including national clinical guidelines, CMS policies, and Humana policies. Responsibilities include computer-based review of clinical scenarios, prioritizing daily work, communicating decisions to internal associates, and potentially participating in care management. The role involves discussions with external physicians to gather clinical information or discuss determinations, sometimes requiring conflict resolution. Some positions may involve overseeing coding practices, clinical documentation, grievance and appeals processes, and outpatient services. The Medical Director will also engage with external physicians, groups, and facilities to support regional market priorities, potentially focusing on value-based care, population health, or disease management, while upholding Humana values and its Bold Goal mission.