Become a part of our caring community
 

The Medical Director relies on their clinical background and reviews preauthorization requests for services. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Medical Director actively uses their medical background, experience, and judgement to make determinations on whether requested services, requested level of care, and/or if a 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 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, 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.

Use your skills to make an impact
 

Responsibilities

The Medical Director provides medical interpretation and determinations on whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. You support and collaborate 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. You enjoy working in a structured environment with expectations for consistency in thinking and authorship. Exercise independence in meeting departmental expectations and meets compliance timelines.

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 by the ABMS or AOA in an approved 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

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

Preferred Qualifications

• Oncology and/or genetics specialty training

• Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid.

• 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

• Advanced degree such as an MBA, MHA, MPH

• Exposure to Public Health, Population Health, analytics, and use of business metrics.

Additional Information

This position reports to a Lead Medical Director. The Medical Director conducts Utilization Management of the care received by members in a member population, or condition type. The Medical Director may also engage in claims and appeals reviews. May participate on project teams or organizational committees.

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Off