Medical Director – Inpatient Review

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🔥 0 minutes ago

🇺🇸 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

• Perform expert clinical review of inpatient medical records for medical necessity • Assess cases using national guidelines, CMS regulations, Humana policies, and recognized clinical standards • Analyze complex hospital-based cases and make utilization management determinations • Communicate with external providers by phone to obtain clinical information and discuss review outcomes • Conduct inpatient medical necessity reviews promptly and according to regulatory requirements • Maintain productivity, accuracy, quality, and timely completion of assigned tasks • Communicate review outcomes clearly and professionally in verbal and written formats • Adapt to changing workflows, tools, and utilization management procedures • Report directly to a Lead Medical Director • Participate in organizational committees or special project teams • Provide rotational weekend and holiday coverage, approximately five weekends per year

🎯 Requirements

• MD or DO • 5 or more years of post-residency clinical experience • Active, unrestricted medical license in at least one state and willingness to obtain additional licenses as needed • Current and ongoing Board Certification in an AOABPS- or ABMS-recognized medical specialty • Must meet all credentialing requirements, with no state or federal sanctions • Strong analytical, communication, and documentation skills • Ability to work effectively within a structured environment and multidisciplinary team • Inpatient exposure, including hospitalist-level acuity, emergency department, intensive care unit, or hospital-based family/internal medicine • Prior utilization management or inpatient review experience preferred • Familiarity with MCG or InterQual guidelines preferred • Experience with Medicare populations and hospitals, integrated delivery networks, or medical management organizations preferred • Proficiency with clinical technology platforms preferred • Ability to work Monday through Friday, 8 a.m. to 5 p.m. local time, with rotational weekend/holiday coverage • Ability to meet remote-work requirements, including internet service with at least 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions and protect PHI/HIPAA information • Occasional travel to Humana offices for training or meetings may be required

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical benefits • Dental benefits • Vision benefits • 401(k) retirement savings plan • Paid time off • Company holidays • Personal holidays • Paid parental leave • Paid caregiver leave • Short-term disability • Long-term disability • Life insurance • Internet expense payment for employees who live and work from home in California, Illinois, Montana, or South Dakota • Telephone equipment appropriate to business requirements • Remote work arrangement • Professional development initiatives • Educational content and team teaching opportunities