Medical Director - One

Overview

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

The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing Home Health, SNF, DME, dual Medicare/Medicaid, Medicaid, IRF and LTACH requests. The Medical Director reviews and determines whether healthcare services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and applicable contracts.

The Medical Director evaluates the medical necessity of healthcare services, ensuring decisions comply with regulatory and organizational standards. The role requires interpreting clinical guidelines, CMS policies, and Medicare requirements, and applying them consistently. All work at One Home is conducted within a framework of regulatory compliance. This secures compliance with all requirements set by federal and state laws. Medical Directors review clinical cases for Medicare and Medicaid members, report to the Lead Medical Director, and work within defined timelines and departmental expectations.

• Review clinical cases and determine medical necessity of services for Medicare and Medicaid members
• Ensure compliance with review policies, procedures, and regulatory standards
• Apply clinical guidelines, CMS policies, and Medicare/Medicare Advantage/Medicaid requirements
• Identify opportunities for medical management operational improvements
• Participate in call rotations, including weekend coverage and after-hours coverage
• Contribute to an engaged, collaborative team culture that supports organizational excellence
• Deliver exceptional consumer experiences
• Support Home Solutions and other activities as assigned by the One Home leadership

Required Qualifications

• MD or DO degree
• Current, active and ongoing board certification from the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialties (AOABPS). National Board of Physicians & Surgeons (NBPAS) certification is not accepted
• Current and unrestricted state license in at least one state and willing to obtain other medical licenses, as required, for various states in region of assignment
• No sanctions from Federal or State Governmental organizations
• 10 years of direct clinical patient care experience post residency or fellowship
• The ability to pass credentialing requirements
• Intermediate to advanced skills utilizing Microsoft Office and Internet navigation
• Strong verbal and written communication skills, with the ability to analyze information and interpret data clearly and accurately
• Adaptable and willing to learn new technologies to enhance workflow efficiency
• Participate in educational activities by attending required conferences and creating content to present for individual subject matter contribution

• Experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
• Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, Surgery or hospital based clinical specialists
• Knowledge and experience with national guidelines such as NCD/LCD, MCG® or Inter Qual

• Workstyle: remote work at home
• Hours: Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM, call rotations, including weekend coverage and after-hours coverage
• Training: 10 weeks of onboarding, no time off and training is in Eastern Standard Time (EST)

Travel:
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

40

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$223,800 - $313,100 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or…