Medical Director- Integrity

Become a part of our caring community and help us put health first

The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized at the Inpatient level. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources.

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

The Medical Director’s work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work and communication of decisions to internal associates. The clinical scenarios predominantly arise from inpatient or post-acute care environments. A remote possibility exists of doing peer-to-peer discussions with an external provider. Some roles include an overview of coding practices and clinical documentation, dispute/grievance and appeals processes, and outpatient services and equipment, within their scope.

Medical Directors support Humana values, and Humana’s mission, throughout all activities.

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. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Lead Medical Director. After completion of mentored training, daily work is performed with minimal direction.

Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines.

Supports the assigned work with respect to market-wide objectives and community relations as directed.

• MD or DO degree
• 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age).
• Current and ongoing Board Certification an approved ABMS Medical Specialty
• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required.
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation.

• Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or 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, Hospitalist, Family Practice, Geriatrics, Emergency Medicine clinical specialists
• Advanced degree such as an MBA, MHA, MPH
• Exposure to Public Health, Population Health, analytics, and use of business metrics.
• The curiosity to learn, the flexibility to adapt and the courage to innovate

Typically reports to a Lead Medical Director. The Medical Director conducts post-service, inpatient care reviews for accurate billing of clinically valid diagnoses and care…