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.
Position Responsibilities:
- Uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and 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.
- Learns Medicaid requirements, understands how to operationalize this knowledge in their daily work and works across different states applying state appropriate requirements.
- 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, with clinical scenarios arising from outpatient, inpatient, or post-acute care environments.
- Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process, and in some instances, these may require conflict resolution skills.
- Oversees coding practices and clinical documentation, grievance, and appeals processes (including pharmacy), and conducts reviews for durable medical equipment (DME), genetic testing, etc. within their scope.
- 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 and a focus on collaborative business relationships, value-based care, population health, or disease or care management.
- Supports Humana values and our enterprise social needs team mission throughout all activities.
- Floats to work as needed within cluster as needed for vacations, weekends, and holidays coverage.
Use your skills to make an impact
Reporting Relationship:
This position reports directly to the Director, Physician Leadership.
REQUIREMENTS:
- Doctor of Medicine or Doctor of Osteopathy.
- Board-certified in ABMS- or AOA-recognized specialty.
- At least five years of experience post-training providing clinical services.
- Experience in utilization management review and case management in a health plan setting.
Preferred:
- Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting.
- Experience with accreditation process (NCQA).
- Experience with CGX and MHK.
- Residence in one of the states in Humana Medicaid national market preferred.
License/Credential Requirement
Physician with an active, unencumbered license in at least one of the states that are part of the Humana Medicaid national market and ability to obtain licenses in other states as necessary.
Location:
This role is based virtually in one of the Humana MCD states.
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 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 Benefits
Humana, 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 us
Humana 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. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our accessibility resources.
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