Medical Director – OP Medicare

🔥 16 hours ago

🇺🇸 United States – Remote

💵 $223.8k - $313.1k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

🦅 H1B Visa Sponsor

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👻 Ghost score 10%

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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, level of care, and site of service • Conduct medical necessity and coverage reviews using CMS policies, Medicare and Medicare Advantage guidelines, clinical criteria, Humana policies, and contractual obligations • Perform computer-based reviews of moderately complex to complex outpatient clinical cases • Evaluate submitted clinical documentation and records to make accurate, evidence-based determinations • Assess whether healthcare services align with national guidelines, clinical standards, CMS requirements, and internal policies • Prioritize and manage daily case review workload to meet compliance-driven turnaround times • Communicate utilization review decisions and clinical determinations to internal associates and relevant stakeholders • Collaborate with external physicians to obtain additional clinical information, discuss determinations, support peer-to-peer reviews, and resolve conflicts during adverse determination discussions • Participate in care management activities to support quality outcomes, care coordination, and appropriate resource utilization • Provide oversight or input on coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment reviews • Collaborate with internal teams, cross-functional partners, Humana colleagues, and regional health services leadership • Engage with contracted physicians, physician groups, facilities, and community organizations • Contribute to value-based care, population health, disease management, and care management initiatives • Work independently after mentored training while meeting quality, productivity, documentation, and compliance expectations • Participate in grievance and appeals reviews, project teams, and organizational committees as applicable

🎯 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 • Demonstrated analytical and interpretive skills • Ability to evaluate information and make informed judgments • Knowledge of the managed care industry, including Medicare Advantage and Managed Medicaid • Utilization management experience in a medical management review organization is preferred • Experience applying national clinical guidelines such as MCG or InterQual is preferred • Advanced degree such as MBA, MHA, or MPH is preferred • Exposure to Public Health, Population Health, analytics, and business metrics is preferred • Experience collaborating with Case Managers or Care Managers on complex case management is preferred • Familiarity with social determinants of health is preferred • Ability to work Monday-Friday during typical business hours, 8 hours/day, 5 days/week • Home internet with minimum 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions to protect PHI/HIPAA information

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