Medical Director – Outpatient Medicare

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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

• Review health claims and clinical documentation for complex cases requiring medical judgment and in-depth analysis • Determine medical necessity and authorize requested services, levels of care, and sites of service • Conduct computer-based reviews of clinical scenarios, primarily involving inpatient and post-acute care settings • Assess medical records against national clinical guidelines, CMS policies, clinical reference materials, and internal policies • Apply Medicare and Medicare Advantage requirements in utilization management decisions • Prioritize daily case reviews and communicate timely, accurate determinations to internal associates and stakeholders • Conduct peer-to-peer discussions with external physicians to obtain clinical information, clarify treatment plans, and discuss authorization decisions • Apply professional judgment and conflict resolution skills to complex or disputed determinations • Interpret whether healthcare services align with clinical standards, regulatory requirements, Humana policies, and applicable contracts • Support grievance and appeals reviews • Provide oversight related to coding practices, clinical documentation, outpatient services, and durable medical equipment where applicable • Collaborate with care management, cross-functional teams, regional leadership, and other Humana departments • Build relationships with contracted physicians, physician groups, facilities, and community partners • Support value-based care, population health, and regional market initiatives • Conduct utilization management for members in an assigned market, population, or condition type • Participate in project teams and organizational committees as needed • 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 • Experience preferably including inpatient care and/or care of a Medicare-type population • 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 • Professional, prompt verbal and written communication skills • Analytic and interpretation skills • Prior experience participating in teams focused on quality management, utilization management, case management, discharge planning, home health, or post-acute services • Preferred specialties include pulmonology, sleep medicine, cardiology, general surgery, radiology, interventional radiology, and genetics • Knowledge of managed care, Medicare Advantage, and Managed Medicaid • Utilization management experience in Medicare Advantage, managed Medicaid, Commercial health insurance, or a medical management review organization • Experience with MCG® or InterQual national guidelines • Knowledge or exposure to Public Health, Population Health, analytics, and business metrics • Experience working with Case managers or Care managers on complex case management • Familiarity with social determinants of health • Ability to work Monday-Friday, 8 hours/day, 5 days/week • Home internet service with at least 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 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 • Occasional travel to Humana offices for training or meetings • Flexible work hours may be possible depending on business needs • Dedicated home workspace • Home internet requirements and support for remote work