Medical Director, National OP – Medicare

🕒 October 21

🇺🇸 United States – Remote

💵 $223.8k - $313.1k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Review preauthorization requests for services • Determine whether requested services, level of care, and/or site of service should be authorized • Apply national clinical guidelines, CMS policies and determinations, Humana policies, clinical standards, and contract requirements • Review submitted clinical records and complex clinical scenarios using computer-based systems • Prioritize daily work and communicate decisions to internal associates • Participate in care management, grievance and appeals reviews, project teams, and organizational committees as applicable • Discuss cases and determinations with external physicians by phone • Gather additional clinical information and resolve conflicts when necessary • Review coding practices, clinical documentation, outpatient services, and equipment within scope • Support regional market priorities and collaborative business relationships • Collaborate with team members, departments, Humana colleagues, and the Regional VP, Health Services • Complete mentored training and perform daily responsibilities with minimal direction • Produce consistent clinical thinking and written determinations • Meet departmental expectations and compliance timelines • Conduct Utilization Management for members in an assigned market, population, or condition type • Report typically to a Regional Vice President of Health Services, Lead, or Corporate Medical Director

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience post residency or fellowship • Current and ongoing Board Certification in an approved ABMS Medical Specialty • Current and unrestricted license in at least one jurisdiction • Willingness to obtain additional license, if required • No current sanction from Federal or State Governmental organizations • Able to pass credentialing requirements • Excellent verbal and written communication skills • Evidence of analytic and interpretation skills • Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid (preferred) • Utilization management experience in a medical management review organization (preferred) • Experience with national guidelines such as MCG® or InterQual (preferred) • Advanced degree such as an MBA, MHA, MPH (preferred) • Exposure to Public Health, Population Health, analytics, and business metrics (preferred) • Experience working with Case managers or Care managers on complex case management (preferred) • Familiarity with social determinants of health (preferred) • Must work remotely within the contiguous United States • Typical availability during Monday-Friday, 8am-5pm business hours, with flexibility based on business needs

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Work from home arrangement • Occasional travel to Humana offices for training or meetings • Dedicated workspace and internet requirements for home employees

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