Medical Director - OP Medicare

at Humana in Dover, Delaware, United States Job Description 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 equipment reviews. + Collaborate with internal team members, cross-functional departments, Humana colleagues, and regional health services leadership to support organizational and market goals. + Engage with contracted physicians, physician groups, facilities, and community organizations to support regional priorities and strengthen collaborative business relationships. + Contribute to initiatives related to value-based care, population health, disease management, and care management strategies. + Work effectively in a structured environment with strong expectations for consistency in clinical reasoning, written determinations, and documentation. + Perform daily responsibilities independently after mentored training, exercising sound judgment with minimal direction. + Meet departmental expectations for quality, consistency, productivity, and compliance timelines. Required Qualifications + 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). + Current and ongoing Board Certification in an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, 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 + The curiosity to learn, the flexibility to adapt and the courage to innovate. Preferred Qualifications + Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid. + 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 InterQual + Advanced degree such as an

MBA , MHA , MPH

+ Exposure to Public Health, 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 innovate. Additional 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. May participate on project teams or organizational committees. Work at Home Guidance To ensure Home or Hybrid Home/Office associates have the self-provided internet service you must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested + Leadership approves satellite, cellular and microwave connection for use only if they give approval. + Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. + Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet our requirements for their position/job. + Work from a dedicated space lacking ongoing interruptions to protect member

PHI / HIPAA

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Travel:

While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job rel To view full details and how to apply, please login or create a Job Seeker account