Become a part of our caring community and help us put health first
 

The Medical Director’s primary responsibility is the review of medical authorizations to determine the medical necessity of a given service, level of care, or medical item/supply. The Medical Director’s work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors that rely on clinical experience and knowledge of both medicine and social determinants of health. Candidates must have current/active Florida license and be willing to work East Coast hours. Please see position requirements for licensing details.

Candidates must have current/active Florida medical license and be willing to work East Coast hours. Please see position requirements for licensing details. 

The LTSS Reviewing Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, requested site of service, and/or medical supply should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources.  Medical Director will learn National LTSS State Medicaid requirements (currently FL; IN; and other states as needed) and understand how to operationalize this knowledge into their daily work.

 

The LTSS Reviewing Medical Director’s work 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, Grievance & Appeal reviews, participation in ICT’s (Intra Collaborative Team meetings); and attend Fair Hearings. The clinical scenarios arise from outpatient, post-acute care; acute inpatient; LTC (Long Term Care); and HCBS (home and community based services) environments. Reviews include, but not limited to,  home health services, therapy services, consumable medical supplies (CMS); home or vehicle modifications, and durable medical equipment (DME).

 

Other duties include, but may not be limited to, an overview of clinical documentation, Letter of Agreements, coding practices, Clinical Integration, Long Term Services & Supports, and  Case Management.  The Medical Director, as indicated, could need to have discussions with external physicians, providers, Care Coaches, and UM Team associates by phone or internal messaging to gather additional clinical information or discuss determinations, and in some instances these discussions may require conflict resolution skills.

 

The LTSS Reviewing Medical Director may occasionally speak with contracted external physicians, provider groups, health care facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value based care, population health, or disease or care management.

Use your skills to make an impact
 

Responsibilities

The Medical Director 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.   The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines.  

               

Required Qualifications

• 5+ years of clinical experience
• Must have a current License in Florida and able to obtain License/s in Indiana, Virginia, Georgia, and/or other LTSS Medicaid states as needed
• MD or DO degree
• Board Certified in an approved ABMS Medical Specialty
• Excellent communication skills with 5+ years of established clinical experience
• Knowledge of the managed care industry including Medicare or Medicaid products
• Possess analysis and interpretation skills with 5+ years of experience focusing on quality management, utilization management, discharge planning, rehabilitation services, and/or home health services