Description
The Medical Director uses their medical background, experience, and judgement to make determinations on authorizing requested services, level of care, and site of service at the Initial or Appeals/Disputes level. All work occurs within a context of regulatory compliance, supported by diverse resources including national clinical guidelines, CMS policies, and clinical reference materials.
The role involves computer-based review of moderately complex to complex clinical scenarios, review of 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, outpatient, or post-acute care environments, requiring discussions for determinations and conflict resolution skills.
The Medical Director provides medical interpretation and determinations on services provided by other healthcare professionals, ensuring agreement with national guidelines, CMS requirements, Humana policies, and clinical standards. They support and collaborate with other team members, departments, and Humana colleagues.
After completion of mentored training, the Medical Director performs daily work independently.
Responsibilities
- Provide medical interpretation and determinations on services provided by other healthcare professionals
- Support and collaborate with other team members, departments, and Humana colleagues
- Conduct Utilization Management of care received by members in an assigned market, member population, or condition type
- Contribute to dispute and appeals reviews
- Participate on project teams or organizational committees
Required Qualifications
- MD or DO degree
- 5+ years of direct clinical patient care experience post-residency or fellowship, including time in an inpatient and/or outpatient environment and care of a Medicare-type population
- Current and ongoing Board Certification in an approved ABMS or AOA Medical Specialty
- Current and unrestricted license in at least one jurisdiction, with willingness to obtain additional licenses
- No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
- Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning, and home health or post-acute services
- Knowledge of the managed care industry, including Medicare Advantage, Managed Medicaid, and Commercial products
- Utilization management experience in a medical management review organization
- Experience with national guidelines such as MCG or InterQual
Preferred Qualifications
- Multiple licenses
- Exposure to Public Health, Population Health, analytics, and use of business metrics
- Experience with Medicare Advantage, Medicaid Claims medical reviews
- Experience working with Case managers or Care managers on complex case management
Additional Information
- The Medical Director reports to the Lead Medical Director, depending on the line of business
- Occasional travel to Humana's offices for training or meetings may be required
- The role requires a dedicated workspace lacking ongoing interruptions to protect member PHI/HIPAA information
Scheduled Weekly Hours
- 40 hours per week
Pay Range
- $223,800 - $313,100 per year
Description of 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 other opportunities