Medical Director - PI, Claims

Humana

18d • $223,800 - $313,100 • Remote

About The Position

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. 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, 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 sources of expertise. 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 activites.

Requirements

• 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 onboarding 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 rehabilitation.

Nice To Haves

• 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 InterQual
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists
• 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

Responsibilities

• Provide medical interpretation and clinical determinations regarding whether services provided by healthcare professionals align with applicable national guidelines, CMS requirements, Humana policies, clinical standards, and relevant contract requirements.
• Review clinical information and apply evidence-based criteria to support consistent, compliant, and well-documented medical decisions.
• Collaborate with team members, cross-functional departments, Humana colleagues, and the Regional VP of Health Services to support departmental and market-wide objectives.
• Perform daily work with minimal direction after completion of mentored training, while maintaining alignment with departmental standards and expectations.
• Work effectively in a structured environment that requires consistency in clinical reasoning, decision-making, documentation, and authorship.
• Exercise independent judgment in meeting departmental expectations, operational goals, and compliance timelines.
• Support market-wide health objectives, including initiatives such as Bold Goal, and contribute to community relations activities as directed.
• Partner with internal stakeholders to promote quality outcomes, appropriate utilization, and adherence to clinical and regulatory requirements.
• Maintain current knowledge of applicable clinical standards, regulatory guidance, CMS requirements, and organizational policies relevant to medical decision-making.
• Communicate clinical determinations clearly and professionally to appropriate internal and external stakeholders.
• Contribute to process consistency, quality improvement, and operational effectiveness within the assigned area of responsibility.
• Demonstrate professionalism, accountability, and collaboration in support of Humana’s clinical, compliance, and business objectives.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree