Medical Director – National OP Medicare

🔥 1 minute 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

• Review preauthorization requests for services • Make determinations on requested services, levels of care, and sites of service • Review clinical records and complex clinical scenarios using national clinical guidelines, CMS policies, clinical references, and Humana policies • Prioritize daily computer-based review work • Communicate decisions to internal associates • Participate in care management when applicable • Discuss cases and determinations with external physicians by phone • Gather additional clinical information and resolve conflicts when necessary • Review coding practices, clinical documentation, grievance and appeals processes, outpatient services, and equipment within scope • Support regional market priorities through communication with external physicians, physician groups, facilities, or community groups • Provide medical interpretation and determinations for healthcare services • Collaborate with team members, departments, Humana colleagues, and the Regional VP Health Services • Complete mentored training and perform daily work with minimal direction • Meet departmental expectations, compliance timelines, and standards for consistency • Conduct utilization management for members in an assigned market, population, or condition type • Participate in grievance and appeals reviews, project teams, or organizational committees

🎯 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/AOA 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 use of business metrics (preferred) • Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health (preferred) • Minimum home internet speed of 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

🏖️ 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 to support remote work

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