Medical Director - National UM

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, level of care, and/or site of service should be authorized. 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 and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.

Weekend work required one weekend per month with compensated days off during the work week.

The Medical Director’s work includes reviewing all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative professional relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment.

Medical Directors support Humana values throughout all activities.

• Conduct comprehensive, timely, and compliant medical necessity reviews for inpatient services
• Maintain accountability for productivity, quality, and compliance metrics
• Communicate determinations clearly both verbally and in writing
• Demonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practices
• Weekend work required one weekend per month with compensated days off during the work week

• MD or DO degree
• 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some 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 working in a team environment

• 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, or other healthcare providers.
• 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
• Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and hospital-based clinical specialists
• The curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals.
• Ability to thrive in a dynamic fast-paced, team-oriented environment.
• Commitment to a culture of innovation, including being facile with using technology to improve workflows
• Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution
• Passionate about contributing to an organization’s focus on consistency in outcomes, consumer experiences and a highly engaged team culture

The medical director reports to a Lead Medical Director.

Participation in weekend work on a rotational basis to ensure cases are decisioned in a timely manner.

May participate on project teams or organizational committees.

Travel:
While this is…