[Remote] PCO Medical Director- UM - Full Time 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 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
Reviews health claims involving moderately complex to complex issues, requiring in-depth evaluation of variable factors
Actively uses medical background, experience, and judgement to make determinations on whether requested services, level of care, and/or site of service should be authorized, within a context of regulatory compliance
Learns Medicare and Medicare Advantage requirements and operationalizes this knowledge in daily work
Performs computer-based review of moderately complex to complex clinical scenarios, reviews submitted clinical records, prioritizes daily work
Communicates decisions to internal associates, participates in care management and possible participation in care facilitation with hospitals
Discusses with external physicians by phone to gather additional clinical information or discuss determinations, which may require conflict resolution skills
Provides overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within scope
Speaks with contracted external physicians, physician groups, facilities, or community groups to support regional market care facilitation and priorities, including understanding of Humana processes, collaborative business relationships, value-based care, population health, or disease or care management
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 in a structured environment with expectations for consistency in thinking and authorship, exercises independence in meeting departmental expectations and meets compliance timelines

Skills

Key technologies and capabilities for this role

Medical ReviewClaims ReviewUtilization ManagementMedicareMedicare AdvantageClinical GuidelinesCMS PoliciesCare ManagementConflict ResolutionCoding PracticesClinical Documentation

Questions & Answers

Common questions about this position

Is this a full-time position?

Yes, this is a full-time role.

What are the main responsibilities of the Medical Director?

The Medical Director reviews health claims, makes determinations on requested services, level of care, and site of service using medical background and judgment, ensures regulatory compliance, and engages in computer-based reviews, communications, and discussions with external physicians.

What skills or experience are required for this role?

The role requires a medical background, experience in reviewing complex clinical scenarios, knowledge of Medicare and Medicare Advantage requirements, regulatory compliance, conflict resolution skills, and the ability to collaborate with team members and external physicians.

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

The role involves working within a caring community, collaborating with team members, other departments, Humana colleagues, and the Regional VP Health Services, with a focus on supportive relationships and minimal direction after training.

What makes a strong candidate for the Medical Director role?

A strong candidate has a solid medical background, experience with complex clinical reviews, knowledge of Medicare requirements, strong judgment for decision-making, collaboration skills, and the ability to work independently after training.

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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