The Medical Director relies on medical background and reviews preauthorization requests for services. 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

The Medical Director for the National Medicare Outpatient Team 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. Primary work reviewing prior-authorization reviews as well as some claims and provider dispute cases for outpatient reviews.

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 and clinical standards. The ideal candidate supports and collaborates with other team members, other departments and Humana colleagues. After completion of mentored training, daily work is performed with minimal direction. 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 and community relations as directed. May participate on project teams or organizational committees. Reports to a Lead Medical Director.

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, 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 NCD/LCD, MCG® or InterQual.

• Advanced degree such as an MBA, MHA, MPH

• Prior experience participating in teams focusing on quality management or utilization management.

Additional Information

Reports to a Lead Medical Director. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. 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.

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Scheduled Weekly Hours

40