Physical Health Medical Director

Humana

4d • $223,800 - $313,100 • Remote

About The Position

The Medical Director is responsible for Medicaid care strategy and/or operations. 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.

Requirements

• Doctor of Medicine or Doctor of Osteopathy
• Board-certified in ABMS recognized specialty
• A current and unrestricted license in at least one of the states that are part of the specific cluster: IN, OH, KY, VA, WI, & IL and ability to obtain unrestricted licenses in the other cluster states that require licensure.
• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting
• Experience with accreditation process (NCQA)
• Experience with CGX and MHK
• Experience in utilization management review and case management in a health plan setting
• Self-provided internet service must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Responsibilities

• Use clinical training, professional experience, and sound medical judgment to determine whether requested services, level of care, or site of service should be authorized.
• Make determinations in accordance with regulatory and compliance requirements and with support from approved resources, including national clinical guidelines, state Medicaid policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other established sources.
• Develop and maintain a working knowledge of Medicaid requirements and apply that knowledge effectively in daily work within the assigned cluster.
• Perform computer-based reviews of moderately complex to highly complex clinical cases from both outpatient and inpatient settings.
• Review all submitted clinical documentation and supporting records to determine medical necessity and appropriateness of care.
• Prioritize daily review work to meet operational expectations and turnaround requirements.
• Communicate determinations and rationale to internal associates in a timely and professional manner.
• Participate in care management-related activities, as appropriate.
• Conduct peer-to-peer discussions with external physicians by phone to obtain additional clinical information and discuss medical necessity determinations.
• Use effective communication and conflict resolution skills in peer-to-peer conversations, particularly in cases involving disagreement or escalated review.
• Collaborate with contracted physicians, physician groups, facilities, and community organizations in support of regional market priorities.
• Demonstrate knowledge of Humana processes while fostering collaborative relationships that support value-based care, population health, and disease or care management initiatives.
• Support Humana’s values and the mission of the Enterprise Social Needs team in all activities and interactions.
• Provide cross-coverage and flow to work across the assigned cluster, as needed, for vacations, weekends, and holiday coverage.

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