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 meet authorization requirements. 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.
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 align 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 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. Completes other duties as assigned.
This is a full-time (approximately 40 hours) work from home opportunity. Candidates may live anywhere in the US and work forty hours per week.
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 acute inpatient rehabilitation
- Board Certified in an approved ABMS Medical Specialty or AOA (American Osteopathic Association) 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
Additional InformationTypically reports to a Lead, may also report to a Regional/Associate Vice President 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. Some medical directors may join a centralized team for several months after training, until positions become available for specific markets. May participate on project teams or organizational committees.
Work at Home GuidanceTo ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
- At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
- Satellite, cellular and microwave connection can be used only if approved by leadership
- Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
- Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Scheduled Weekly Hours40
Pay RangeThe 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 demonstrated job related skills, knowledge, experience, education, certifications, etc. $199,400 - $274,400 per year. This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About usHumana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it.
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