Medical Director - Claims

Overview

Become a part of our caring community

The Medical Director uses their medical background, experience, and judgement. You will make determinations whether they should authorize requested services, request level of care, and requested site of service at the Initial or Appeals/Disputes level. All work occurs within a context of regulatory compliance. Diverse resources assist work, including national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources.

You will learn Medicare, Medicaid, and Medicare Advantage requirements and understand how to operationalize this knowledge in their daily work.

Your work includes computer-based review of moderately complex to complex clinical scenarios. This work also includes review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. The clinical scenarios predominantly arise from inpatient, outpatient, or post-acute care environments. You will have discussions with external physicians by phone to gather additional clinical information or discuss determinations, and in some instances, these may require conflict resolution skills.

Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.

You may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities. These priorities may include an understanding of Humana processes, and a focus on collaborative business relationships, values-based care, population health, or disease or care management.

Use your skills to make an impact

• The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. You support and collaborate with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, you will perform daily work.

• MD or DO degree

• You have 5+ years of direct clinical patient care experience post residency or fellowship. This experience includes time in an inpatient environment and care of a Medicare type population, such as the disabled or those over 65 years of age.

• Current and ongoing Board Certification an approved ABMS or AOA Medical Specialty

• You have a current and unrestricted license in at least one jurisdiction and are willing to obtain additional licenses.

• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.

• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and home health or post-acute services such as inpatient rehabilitation.

• Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and Commercial products, or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.

• Utilization management experience in a medical management review organization, such as Medicare Advantage, Managed Medicaid, or Commercial health insurance.

• Experience with national guidelines such as MCG® or Inter Qual

• Internal Medicine, Family Practice, Geriatrics, Hospitalist, and Emergency Medicine clinical specialists

• Advanced degrees such as an MBA, MHA, 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.

You will report to the Lead Medical Director, depending on the line of business. The Medical Director conducts Utilization Management…