Medical Director – National OP, Medicare

🔥 3 minutes ago

🇺🇸 United States – Remote

💵 $223.8k - $313.1k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

🦅 H1B Visa Sponsor

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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 • Review submitted clinical records and computer-based clinical scenarios • Prioritize daily work and communicate decisions to internal associates • Participate in care management, grievance and appeals reviews, project teams, or organizational committees as applicable • Conduct Utilization Management for members in an assigned market, member population, or condition type • Interpret whether services align with national guidelines, CMS requirements, Humana policies, clinical standards, and contract requirements • Support and collaborate with team members, departments, Humana colleagues, and the Regional VP of Health Services • Communicate with external physicians by phone to gather clinical information or discuss determinations • Resolve conflicts during physician discussions when necessary • Support regional market priorities and collaborative business relationships with external physicians, physician groups, facilities, or community groups • Meet departmental expectations independently and consistently • Ensure compliance timelines are met • 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 • Ability 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, 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, including familiarity with social determinants of health (preferred) • Dedicated work space without ongoing interruptions to protect member PHI/HIPAA information • Home internet service with at least 25 Mbps download and 10 Mbps upload speed

🏖️ 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 holidays • Personal holidays • Paid parental leave • Paid caregiver leave • Short-term disability • Long-term disability • Life insurance • Work-from-home arrangement • Potential travel to Humana offices for training or meetings