HireMO

Become a part of our caring community

The Medical Director relies on medical 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 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.

Responsibilities

The Medical Director 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. 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 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 in an approved ABMS/AOA 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

+ 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.

+ Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.

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

Reporting Structure

Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees.

Work Style: Fully Remote

Occasional travel to Humana's offices for training or meetings may be required.

Work Hours : Typical business hours are Monday-Friday, some flexibility might be possible, depending on business needs.

Interview Format

As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers with an enhanced method for decision-making through on-demand candidate assessments.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions. You should anticipate the assessment to take approximately 10-15 minutes.

Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

SSN Task via Workday

Should you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.

\#physiciancareers #managedcare

\#medicareadvantage #reviewingmd

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstra...

Apply Externally

Jobs

Medical Director National OP Medicare

Summary

You Need a MO Jobs Account First

Jobs

Jobs

Medical Director National OP Medicare

Summary

Do You Have a MO Jobs Account?

First, Let's Find Your MO Jobs Account

Create an Account to Apply

You Need a MO Jobs Account First

HireMO Terms of Use

1. Acceptance and Changes

2. A No-Cost Public Workforce Service

3. Eligibility, Youth, and Authority

4. Accounts and Security

5. Accuracy Attestation and Program Information

6. Job Seeker Terms

7. Employer Terms

8. Assessments and Matching

9. Artificial Intelligence Features

10. Public Records and Required Notices

11. User Content and Permissions

12. Acceptable Use

13. Intellectual Property and Government Marks

14. Other Users and Third-Party Services

15. Electronic Communications

16. Suspension, Termination, and Records

17. Disclaimers

18. Limitation of Liability and Sovereign Immunity

19. Employer Indemnification

20. Governing Law and General Terms

21. Contact, Accessibility, and Complaints