Medical Director – Medicaid

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⚜️ Louisiana, Oklahoma – Remote

⚜️ Louisiana – Remote 🌪️ Oklahoma – 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 health claims and clinical records • Determine whether requested services, levels of care, and sites of service should be authorized • Apply national clinical guidelines, CMS policies, clinical standards, Humana policies, and contracts • Prioritize daily computer-based clinical review work • Communicate determinations to internal associates • Discuss cases with external physicians by phone and gather additional clinical information • Resolve conflicts related to medical determinations when necessary • Participate in care management, grievance and appeals reviews, project teams, and organizational committees • Conduct Utilization Management for members in an assigned market, population, or condition type • Support regional market priorities, value-based care, population health, disease management, and care management initiatives • Collaborate with team members, departments, Humana colleagues, and the Regional VP Health Services • Complete mentored training and then perform daily work with minimal direction • Support market-wide objectives and community relations as directed • Typically report 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 Louisiana and Oklahoma licenses, and/or ability to obtain additional licenses without conditions • No current sanction from Federal or State Governmental organizations • Able to pass credentialing requirements • Position open to all US Territory, with requirement to work 8am-5pm Central Standard Time • Excellent verbal and written communication skills • Analytic and interpretation skills • Prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services • Ability to conduct Utilization Management • Preferred: knowledge of managed care industry, Medicare Advantage, Managed Medicaid and/or Commercial products • Preferred: utilization management experience in a medical management review organization • Preferred: experience with MCG® or InterQual • Preferred: Family Practice, Pediatrics, Physical Medicine Rehabilitation, or Emergency Medicine specialization • Preferred: advanced degree such as MBA, MHA, or 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 and familiarity with social determinants of health

🏖️ 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 • Dedicated home workspace and internet requirements for remote work • Occasional travel to Humana offices for training or meetings

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