Physical Health Medical Director

🔥 0 minutes ago

🌽 Illinois, Kentucky, +3 more states – Remote

🌽 Illinois – Remote 🐎 Kentucky – Remote 🏈 Ohio – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – 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

• Determine whether requested services, level of care, or site of service should be authorized • Make determinations according to regulatory, compliance, clinical guideline, Medicaid, and CMS requirements • Develop and maintain knowledge of Medicaid requirements for the assigned cluster • Perform computer-based reviews of moderately complex to highly complex outpatient and inpatient clinical cases • Review clinical documentation and supporting records for medical necessity and appropriateness of care • Prioritize daily review work to meet operational and turnaround requirements • Communicate determinations and rationale to internal associates • Participate in care management-related activities • Conduct peer-to-peer discussions with external physicians by phone • Apply communication and conflict resolution skills during peer-to-peer conversations • Collaborate with contracted physicians, physician groups, facilities, and community organizations • Support value-based care, population health, and disease or care management initiatives • Support Humana’s values and the Enterprise Social Needs team mission • Provide cross-coverage across the assigned cluster for vacations, weekends, and holidays • Report directly to the Cluster Lead Medical Director

🎯 Requirements

• Doctor of Medicine or Doctor of Osteopathy • Board-certified in an ABMS recognized specialty • Current and unrestricted license in at least one state in the specific cluster: IN, OH, KY, VA, WI, or IL • Ability to obtain unrestricted licenses in the other cluster states that require licensure • Experience working with Medicaid enrollees, providers, and stakeholders in a clinical or administrative setting • Experience with accreditation processes, including NCQA • Experience with CGX and MHK • Experience in utilization management review and case management in a health plan setting • Ability to work Monday–Friday, 8 hours/day, 5 days/week • Minimum home internet speed of 25 Mbps download and 10 Mbps upload • Dedicated workspace 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 • Occasional travel to Humana offices for training or meetings