Physical Health Medical Director

Humana • Work at Home - Ohio, OH

3d • 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. This role is based virtually in one of the states of the specific cluster. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Requirements

• Doctor of Medicine or Doctor of Osteopathy
• Board-certified in ABMS or ABOA recognized specialty
• A current and unrestricted license in at least one of the states that are part of the specific cluster, if required
• 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.

Nice To Haves

• 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
• Has a medical license in at least one of the states that are part of the specific cluster

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.
• All work occurring within a context of regulatory compliance and assisted by diverse resources, which may include national clinical guidelines, state policies, and CMS policies and determinations.
• 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.
• 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.
• Peer-to-peer process that may require conflict resolution skills.
• May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities.
• May include an understanding of Humana processes and a focus on collaborative business relationships, value-based care, population health, and chronic disease 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, 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: Mid Level
• Education Level: Ph.D. or professional degree