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 their medical background to review health claims. This role involves moderately complex to complex work assignments where the analysis of situations or data requires an in-depth evaluation of variable factors. The Medical Director actively uses their medical background, experience, and judgment to make determinations on whether requested services, level of care, and/or site of service should be authorized. All work is performed within a context of regulatory compliance and is supported by diverse resources, including national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise.

Medical Directors will learn Medicaid requirements and understand how to operationalize this knowledge in their daily work. The role includes 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 potential participation in care management. Clinical scenarios predominantly arise from inpatient or post-acute care environments. Regular discussions with external physicians by phone are expected to gather additional clinical information or discuss determinations, which may require conflict resolution skills. Some roles may include an overview of coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment within their scope.

The Medical Director may also engage with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities. This may involve understanding Humana processes, focusing on collaborative business relationships, value-based care, population health, or disease/care management.

Use your skills to make an impact.

Responsibilities

• 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.
• Supports and collaborates with other team members, other departments, Humana colleagues, and the Regional VP Health Services.
• After completion of mentored training, performs daily work with minimal direction.
• Enjoys working in a structured environment with expectations for consistency in thinking and authorship.
• Exercises independence in meeting departmental expectations and compliance timelines.

Required Qualifications

• MD or DO degree
• 5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience in an inpatient environment and/or related to the care of a Medicaid population (disabled or >65 years of age).
• Current and ongoing Board Certification in an approved ABMS Medical Specialty.
• 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.

Preferred Qualifications

• Experience in Managed Medicaid or other Medical Management organizations, hospitals/Integrated Delivery Systems, health insurance, other healthcare providers, or clinical group practice management.
• A current and unrestricted license in Florida and willingness to obtain licensure in South Carolina and Georgia, and additional licenses if required.
• Utilization management experience.

Company Information

• Location Type: (Information not provided)
• Salary: (Information not provided)