Medical Director - Acute Rehab

Humana

2d•$223,800 - $313,100•Remote

About The Position

The Medical Director uses medical background, experience, and judgment to determine whether to authorize requested services, levels of care, and sites of service. The role operates within regulatory requirements and draws on national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other resources. The Medical Director learns Medicare and Medicare Advantage requirements and applies them in daily work, particularly for DSNP. The position involves computer-based review of moderately complex to complex clinical scenarios, examination of submitted clinical records, prioritization of daily work, and communication of decisions to internal associates. Most scenarios arise from post-acute care environments. The role also includes phone discussions with external physicians to obtain clinical information or discuss determinations, sometimes requiring conflict resolution. This is a full-time, fully remote position for applicants living in the contiguous United States, with a standard schedule of 40 hours per week. Typical business hours are Monday through Friday, with a start time between 6 a.m. and 9 a.m.; some flexibility may be possible depending on business needs. Occasional travel to Humana offices for training or meetings may be required. Employees working from home must have internet service with at least 25 Mbps download and 10 Mbps upload speeds and a dedicated workspace that protects member PHI/HIPAA information. The role conducts utilization management of care received by members in an assigned market, population, or condition type, and may contribute to grievance and appeals reviews. Some Medical Directors may work on a centralized team for several months after training while waiting for a position in a specific market. The role may also participate in project teams or organizational committees. It typically reports to a Regional/Associate Vice President, Lead, or Corporate Medical Director, depending on region or line of business. The stated annual base-pay range is $223,800–$313,100, with individual pay varying by location and job-related qualifications. The role is eligible for a bonus incentive plan based on company and/or individual performance.

Requirements

MD or DO degree.
At least 5 years of direct clinical patient-care experience after residency or fellowship; inpatient experience and experience related to acute inpatient rehabilitation are preferred within this qualification.
Board certification in an approved ABMS or AOA medical specialty, maintained throughout employment.
Current, unrestricted license in at least one jurisdiction and willingness to obtain additional licenses.
No current sanctions from Federal or State Governmental organizations and ability to pass credentialing requirements.
Demonstrated analytical and interpretation skills, with prior experience participating in teams focused on quality management, utilization management, and acute inpatient rehabilitation.
Knowledge of the managed care industry, including Medicare Advantage, Managed Medicaid, medical management organizations, hospitals/Integrated Delivery Systems, health insurance, or other healthcare providers.
Utilization management experience in a medical management review organization, such as Medicare Advantage or managed Medicaid.
Background in Physical Medicine and Rehabilitation, Internal Medicine, Family Practice, Geriatrics, or Hospitalist medicine.
Ability to work from a dedicated space that protects member PHI/HIPAA information and meet the stated home internet requirements: at least 25 Mbps download and 10 Mbps upload.
Must live in the contiguous United States.

Nice To Haves

Advanced degree such as an MBA, MHA, or 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.
Inpatient experience and experience related to acute inpatient rehabilitation.

Responsibilities

Provide medical interpretation and determinations on acute inpatient rehabilitation authorization requests, aligning decisions with national clinical guidelines, CMS requirements, Humana policies, and clinical standards.
Review submitted clinical records and clinical scenarios, prioritize daily work, and communicate determinations to internal associates.
Discuss cases with external physicians by phone to obtain additional clinical information or discuss determinations, using conflict-resolution skills when needed.
Collaborate with team members, other departments, Humana colleagues, and clinical leadership to support review processes and quality outcomes.
Participate in and complete structured, mentored training programs and use ongoing team support during daily work.
Apply critical thinking and maintain high standards of documentation and decision-making in a structured work environment.
Meet enterprise expectations and compliance timelines independently.
Conduct utilization management of care for members in an assigned market, population, or condition type.
Contribute to grievance and appeals reviews when applicable.
Participate in project teams or organizational committees when applicable.