Medical Director - OP Medicare

Job Listing ID:

4494341

Job Title:

Medical Director -

OP Medicare Application Deadline:

Open Until Filled

Job Location:

Salem

Date Posted:

05/19/2026

Hours Worked Per Week:

Not Provided Shift:

Not Provided Duration of Job:

Either Full or Part Time, more than 6 months You may contact this employer directly. (Obtain the contact information to print or add to your jobs.)

Job Summary:

Become a part of our caring community The Medical Director National OP Medicare relies on medical background and reviews preauthorization requests for services. You will work assignments that involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. 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 with a context of regulatory compliance. Work is assisted by diverse resources which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise. You 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, 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. You will have 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. This 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. Use your skills to make an impact Responsibilities Use clinical expertise, medical judgment, and experience to determine authorization for requested services, level of care, and site of service. Perform medical necessity reviews in compliance with regulatory standards, CMS requirements, Humana policies, clinical guidelines, and applicable contractual obligations. Apply knowledge of Medicare and Medicare Advantage requirements in daily utilization management and coverage determination activities. Conduct computer-based review of moderately complex to complex clinical cases, primarily involving inpatient and post-acute care scenarios. Review all submitted clinical documentation and records to support accurate, evidence-based determinations. Interpret whether services rendered by other healthcare professionals align with national guidelines, clinical standards, CMS requirements, and internal policies. Prioritize daily case review workload to ensure timely completion and adherence to compliance-driven turnaround times. Communicate utilization review decisions and clinical determinations to internal associates and relevant stakeholders. Speak regularly with external physicians to obtain additional clinical information, discuss determinations, and support peer-to-peer review processes. Use conflict resolution skills when needed during physician discussions related to adverse determinations or clinical review outcomes. Participate in care management activities when applicable to support quality, coordination, and appropriate resource utilization. Provide oversight or input, as applicable, regarding coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipme...

Job Classification:

Medical and Health Services Managers Access our statewide or regional occupation report for more information about wages, employment outlooks, skills, training programs, related occupations, and more. Compensation

Salary:

Not Provided Job Requirements

Experience Required:

 See Job Summary

Education Required:

None

Minimum Age:

N/A Gender:

N/A