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, requested level of care, and/or requested 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 specifically for DSNP.

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, and communication of decisions to internal associates. The clinical scenarios predominantly arise from post-acute care environments. The work includes 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.

Responsibilities 

The Medical Director provides medical interpretation and determinations on whether acute inpatient rehabilitation authorization requests are in agreement with national guidelines, CMS requirements, Humana policies, and clinical standards. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and clinical leadership. After completion of structured and mentored training, daily work is performed with minimal direction, but with support from other team members. The Medical Director enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting enterprise expectations and compliance timelines.  

This is a full-time work from home opportunity. Candidates may live anywhere in the US and work forty hours per week.  

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 acute inpatient rehabilitation. 

• Board Certified in an approved ABMS Medical Specialty with continued certification throughout employment. 

• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), 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, and acute inpatient rehabilitation. 

Preferred Qualifications 

• Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers. 

• Utilization management experience in a medical management review organization, such as Medicare Advantage and managed Medicaid. 

• Physical Medicine and Rehabilitation, Internal Medicine, Family Practice, Geriatrics, or Hospitalist background 

• Advanced degree such as an MBA, MHA, or MPH 

• The curiosity to learn, the flexibility to adapt and the courage to innovate