[Remote] PCO Medical Director- UM - Full Time at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, preferably including experience in an inpatient 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 as well as ABQAURP, or other board demonstrating advanced training in transitions of care, quality assurance, utilization management and care coordination
A 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 organizational, verbal and written communication skills

Responsibilities

Provides 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
Supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services
Performs daily work with minimal direction after completion of mentored training
Exercises independence in meeting departmental expectations and meets compliance timelines
Reviews health claims
Analyzes situations or data requiring an in-depth evaluation of variable factors
Makes determinations whether requested services, requested level of care, and/or requested site of service should be authorized
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
Participation in care management and possible participation in care facilitation with hospitals
Discussions with external physicians by phone to gather additional clinical information or discuss determinations
Overview of coding practices and clinical documentation
Review of grievance and appeals processes
Review of outpatient services and equipment
May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market care facilitation and priorities

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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