Humana Medical Director - Mid West Region
Become a part of our caring community and help us put health first
The Medical Director actively uses their medical background, experience, and judgment to make determinations on 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, 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 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. Clinical scenarios predominantly arise from inpatient or post-acute care environments. Regular discussions with external physicians by phone may be required to gather additional clinical information or discuss determinations, which may involve 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. Medical Directors support Humana values and Humana's Bold Goal mission throughout all activities.
Responsibilities
- Provide 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.
- Support and collaborate with other team members, departments, Humana colleagues, and the Regional VP Health Services.
- After completion of structured and mentored training, perform daily work with minimal direction, but with ready support from other team members.
- Work in a structured environment with expectations for consistency in thinking and authorship, exercising independence in meeting departmental expectations and compliance timelines.
Required Qualifications
- MD or DO degree.
- 5+ years of direct clinical patient care experience post-residency or fellowship, preferably including 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 Medical Specialty.
- A current and unrestricted license in at least one jurisdiction and willing to obtain additional licenses, if required.
- No current sanctions 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.
- Utilization management experience in a medical management review organization.
- 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.
Additional Information
Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on the size of the region or line of business. 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 in project teams or organizational committees.
Scheduled Weekly Hours
40
Pay Range
$199,400 - $274,400 per year. This job is eligible for a bonus incentive plan based on company and/or individual performance.
Description of Benefits
Humana, Inc. offers competitive benefits that support whole-person well-being, including medical, dental, and vision benefits, 401(k) retirement savings plan, paid time off, short-term and long-term disability, life insurance, and more.
About us
Humana Inc. is committed to putting health first for our teammates, customers, and the company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for millions to achieve their best health.
Equal Opportunity Employer
Humana does not discriminate against any employee or applicant for employment based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status.
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