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 or claims to determine the medical necessity of a given service or level of care. 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.

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, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources.  Medical Directors will learn North Central region state Medicaid requirements (currently KY, OH, IN) 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 arise from outpatient, inpatient or post-acute care environments. The Medical Director will have discussions with external physicians by phone to gather additional clinical information or discuss determinations through the Peer 2 Peer process, and in some instances these may require conflict resolution skills.  Other duties include, but may not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic testing, etc. within their scope.

The Medical Director may occasionally 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 whether services provided by other healthcare professionals are in agreement with national guidelines, state and CMS requirements, Humana policies, clinical standards, and 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.  Supports the assigned work with respect to market-wide objectives (e.g. Bold Goal) and community relations as directed.

               

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 and/or outpatient environment and/or related to care of a Medicaid population (TANF and expansion populations).
• Current and ongoing Board Certification in an approved ABMS Medical Specialty
• A current and unrestricted license in KY or willing to obtain by start date.  Willingness to obtain additional license(s), as required, but not limited to IN, OH, VA
• 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 gui