Physical Health Medical Director

Humana

3d • $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 or ABPN recognized specialty
• A current and unrestricted license in at least one of the states that are part of the specific cluster, and ability to obtain licenses in the other cluster states that require licensure.
• Able to satisfy onboarding requirements
• At least five years of experience post-training providing clinical services
• Experience in utilization management review and case management in a health plan setting
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting
• Experience with accreditation process (NCQA)
• Experience with CGX and MHK
• Has licensure through the Interstate Medical Licensure Compact

Nice To Haves

• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting
• Experience in utilization management review and case management in a health plan setting
• Experience with accreditation process (NCQA)
• Experience with CGX and MHK
• Has licensure through the Interstate Medical Licensure Compact

Responsibilities

• Uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and assisted by diverse resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources
• Learns Medicaid requirements and understands how to operationalize this knowledge in their daily work in their assigned cluster
• 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, with clinical scenarios arising from outpatient or inpatient environments
• Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process, and in some instances, these may require conflict resolution skills
• 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 and a focus on collaborative business relationships, value-based care, population health, or disease or care management
• Supports Humana values and our enterprise social needs team mission throughout all activities
• Flows to work as needed within cluster as needed for vacations, weekends and holidays 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