Medical Director - Southeast Medicaid

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

The Medical Director relies on medical background and reviews health claims. 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.

The Medical Director uses their medical background, experience, and judgement to make determinations whether they will authorize requested services, request level of care, and requested site of service. All work occurs with a context of regulatory compliance. Diverse resources, including national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise, assist work. Medical Directors will learn Medicaid 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. The work also includes review of all submitted clinical records, prioritization of daily work, and communication of decisions to internal associates. Additionally, the Medical Director may participate in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. 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.

The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups. This supports regional market priorities, which may include understanding Humana processes. Additionally, the focus is on collaborative business relationships, values-based care, population health, or disease or care management.

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 collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed. Enjoy working in a structured environment with expectations for consistency in thinking and authorship.

Exercise independence in meeting departmental expectations and meets compliance timelines.

• MD or DO degree

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

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

• 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.

• Managed Medicaid or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.

• A current and unrestricted license in Florida and willing to obtain licensure in South Carolina and Georgia, and additional license.

• 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 degree such as an MBA, MHA, MPH

• Exposure to Public…