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

The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, level of care, and/or site of service 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, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. 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 reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative business relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment. Medical Directors support Humana value throughout all activities.

Responsibilities

The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant 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 structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. 

 

Use your skills to make an impact
 

​Required Qualifications

• MD or DO degree
• 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes 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  an approved ABMS Medical Specialty
• 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 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

• Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
• Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance.
• Experience with national guidelines such as MCG® or InterQual
• Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists
• Exposure to Public Health, Population Health, analytics, and use of business metrics.
• Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.
• The curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals.

• Ability to thrive in a dynamic fast-paced, team-oriented environment.
• Commitment to a culture of innovation, including being facile with using technology to improve workflows
• Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution
• Passionate about contributing to an organization’s focus on consistency in outcomes, consumer experiences and a highly engaged team culture

• Identify medical management operational improvements, including those within the medical director area
• Participate in