Medical Director

The Medical Director relies on medical background and reviews health claims. 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.

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.

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.

Required Qualifications

• MD or DO degree
• 5+ years of direct clinical patient care experience post residency or fellowship
• Current and ongoing Board Certification an approved ABMS Medical Specialty
• Current Louisiana and Oklahoma licenses, and/or ability to obtain additional licenses without conditions
• 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

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

Benefits Humana offers competitive benefits that support whole-person well-being, including medical, dental and vision benefits, 401(k) retirement savings plan, time off, short-term and long-term disability, life insurance, and many other opportunities.