Medical Director - Southeast Region - Work from Home
Posted on: September 23, 2022
Description The Medical Director relies on medical background
and reviews health claims. The Medical Director work assignments
involve moderately complex to complex issues where the analysis of
situations or data requires an in-depth evaluation of variable
factors.Responsibilities Job Profile The Medical Director actively
uses their medical background, experience, and judgement to make
determinations whether requested services, requested level of care,
and/or requested site of service should be authorized. All work
occurs within a context of regulatory compliance, and work is
assisted by diverse resources, which may include national clinical
guidelines, CMS policies and determinations, clinical reference
materials, internal teaching conferences, and other reference
sources. Medical Directors will learn Medicare and Medicare
Advantage requirements, and will understand how to operationalize
this knowledge in their daily work.The Medical Director's work
includes computer-based review of moderately complex to complex
clinical scenarios, review of all submitted clinical records,
prioritization of daily work, communication of decisions to
internal associates, and possible participation in care management.
The clinical scenarios predominantly arise from inpatient or
post-acute care environments. Has discussions with external
physicians by phone to gather additional clinical information or
discuss determinations regularly, and in some instances these may
require conflict resolution skills. Some roles include an overview
of coding practices and clinical documentation, grievance and
appeals processes, and outpatient services and equipment, within
their scope.The Medical Director may speak with contracted external
physicians, physician groups, facilities, or community groups to
support regional market priorities, which may include an
understanding of Humana processes, as well as a focus on
collaborative business relationships, value based care, population
health, or disease or care management. Medical Directors support
Humana values, and Humana's Bold Goal mission, throughout all
activities.Responsibilities The Medical Director provides medical
interpretation and determinations whether services provided by
other healthcare professionals are in agreement with national
guidelines, CMS requirements, Humana policies, clinical standards,
and (in some cases) contracts. The ideal candidate supports and
collaborates with other team members, other departments, Humana
colleagues and the Regional VP Health Services. After completion of
structured and mentored training, daily work is performed with
minimal direction, but with ready support from other team members.
Enjoys working in a structured environment with expectations for
consistency in thinking and authorship. Exercises independence in
meeting departmental expectations, and meets compliance timelines.
Supports the assigned work with respect to market-wide objectives
(e.g. Bold Goal) and community relations as directed.This is a full
time work from home opportunity. Candidates may live anywhere in
the US, but must be willing to work 8:00 am-5:00 pm Eastern time
zone. There will be one weekend day required per month. Required
- MD or DO degree
- 5+ years of direct clinical patient care experience post
residency or fellowship, which preferably includes some experience
in an inpatient environment and/or related to care of a Medicare
type population (disabled or > 65 years of age).
- Board Certified in an approved ABMS Medical Specialty with
continued certification throughout employment.
- A current and unrestricted license in at least one jurisdiction
and willing to obtain additional license(s), if required.
- No current sanction from Federal or State Governmental
organizations, and able to pass credentialing requirements.
- Excellent verbal and written communication skills.
- Evidence of analytic and interpretation skills, with prior
experience participating in teams focusing on quality management,
utilization management, case management, discharge planning and/or
home health or post-acute services (such as inpatient
- Knowledge of the managed care industry including Medicare
Advantage, Managed Medicaid and/or Commercial products, or other
Medical management organizations, hospitals/ Integrated Delivery
Systems, health insurance, other healthcare providers, clinical
group practice management.
- Utilization management experience in a medical management
review organization, such as Medicare Advantage, managed Medicaid,
or Commercial health insurance.
- Experience with national guidelines such as MCG or
- Internal Medicine, Family Practice, Geriatrics, Hospitalist,
Emergency Medicine clinical specialization
- Advanced degree such as an MBA, MHA, or MPH
- Exposure to Public Health principles, Population Health,
analytics, and use of business metrics.
- Experience working with Case managers or Care managers on
complex case management, including familiarity with social
determinants of health.
- The curiosity to learn, the flexibility to adapt and the
courage to innovateAdditional Information Typically reports to a
Regional Vice President of Health Services, Lead, or Corporate
Medical Director, depending on size of region or line of business.
The Medical Director conducts Utilization Management of the care
received by members in an assigned market, member population, or
condition type. May also engage in grievance and appeals reviews.
Some medical directors may join a centralized team for several
months after training, until positions become available for
specific markets. May participate on project teams or
organizational committees.Humana and its subsidiaries require
vaccinated associates who work outside of their home to submit
proof of vaccination, including COVID-19 boosters. Associates who
remain unvaccinated must either undergo weekly negative COVID
testing OR wear a mask at all times while in a Humana facility or
while working in the field.#physiciancareersScheduled Weekly Hours
40Humana complies with all applicable federal civil rights laws and
does not discriminate on the basis of race, color, national origin,
age, disability, sex, sexual orientation, gender identity or
religion. We also provide free language interpreter services. See
Keywords: Humana, Albuquerque , Medical Director - Southeast Region - Work from Home, Executive , Albuquerque, New Mexico
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