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The Medical Director relies on medical background and reviews health claims. The Medical Director (Staff Geriatrician or Physician with Ten (10) Years of Clinical Practice with Older Adults) works assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

               

The Staff Geriatrician or Physician with Ten (10) Years of Clinical Practice with Older Adults (Medical Director) is dedicated full time to the Indiana Pathways program to assist the Utilization Management, Care Management, and Quality departments’ staff to understand the complex needs and care of older adults.

The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs with a context of regulatory compliance, and work is assisted by diverse resources which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise.  Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work.

The 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, and possible participation in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances these may require conflict resolution skills.  Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.

The Medical Director may speak with contracted external physicians, physician groups, 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. Medical Directors support Humana values, and Humana’s Bold Goal mission, throughout all activites.

Use your skills to make an impact
 

Position 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.
• Completes computer-based reviews of moderately complex to complex clinical scenarios, review of all submitted clinical records and communication of decisions to internal associates.
• Engages in discussions with external physicians to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills.
• Serves as a clinical resource for the duals and long-term services and support (LTSS) program as well as its providers with a focus on developing innovative approaches for improving the quality, efficiency, and appropriateness of care.
• Works in collaboration with team members to develop creative approaches to enhancing the principles of independent living and consumer direction.
• Actively participates in interdisciplinary care team and provides clinical physician support for care and services coordinators and team at large.
• Collaborate with key stakeholders to support efforts to ensure an integrated care continuum that aims to improve utilization and outcomes, quality of care, social determinants of health, and experience for members.
• Provide thought leadership and consulting expertise on population health management approaches and metrics specific to the senior population with a strong lens on intersecting behavioral and social health needs.
• Provide support to Medicaid markets within the region, aiding in case review, peer to peer and appeals as needed.
• Provide weekend and holiday Medical Director coverage in collaboration with other market Medical Directors on a rotating scheduled as needed.

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 in