Medical Director - OneHome

Humana

11d • Remote

About The Position

The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing Home Health, SNF, DME, dual Medicare/Medicaid requests. The Medical Director reviews and determines whether healthcare services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and applicable contracts. The Medical Director evaluates the medical necessity of healthcare services, ensuring decisions comply with regulatory and organizational standards. The role requires interpreting clinical guidelines, CMS policies, and Medicare requirements, and applying them consistently. All work at OneHome is conducted within a framework of regulatory compliance. This secures compliance with all requirements set by federal and state laws. Medical Directors review clinical cases for Medicare and Medicaid members, report to the Lead Medical Director, and work within defined timelines and departmental expectations.

Requirements

• MD or DO degree
• Current, active and ongoing board certification from the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialties (AOABPS). National Board of Physicians & Surgeons (NBPAS) certification is not accepted
• Current and unrestricted state license in at least one state and willing to obtain other medical licenses, as required, for various states in region of assignment
• No sanctions from Federal or State Governmental organizations
• 5 years of direct clinical patient care experience post residency or fellowship
• The ability to pass credentialing requirements
• Intermediate to advanced skills utilizing Microsoft Office and Internet navigation
• Strong verbal and written communication skills, with the ability to analyze information and interpret data clearly and accurately
• Adaptable and willing to learn new technologies to enhance workflow efficiency

Nice To Haves

• Experience in an inpatient and/or outpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
• Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, Surgery or hospital based clinical specialists

Responsibilities

• Review clinical cases and determine medical necessity of services for Medicare and Medicaid members
• Ensure compliance with review policies, procedures, and regulatory standards
• Apply clinical guidelines, CMS policies, and Medicare/Medicare Advantage/Medicaid requirements
• Identify opportunities for medical management operational improvements
• Participate in call rotations, including weekend coverage and after-hours coverage
• Contribute to an engaged, collaborative team culture that supports organizational excellence
• Deliver exceptional consumer experiences
• Support Home Solutions and other activities as assigned by the OneHome leadership
• Use your skills to make an impact

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, 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