Medical Director - Acute Rehab

The Medical Director uses their medical background, experience, and judgement to determine whether to authorize requested services, requested level of care, and requested site of service. All work occurs within a context of regulatory compliance, and diverse resources assist work, including 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 specifically for DSNP.

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 post-acute care environments. The work includes discussions with external physicians by phone to gather additional clinical information or discuss determinations, and in some instances, these may require conflict resolution skills.

• Provide medical interpretation and determinations on acute inpatient rehabilitation authorization requests, ensuring alignment with national clinical guidelines, CMS requirements, Humana policies, and clinical standards.

• Collaborate with team members, other departments, Humana colleagues, and clinical leadership to support the review process and facilitate quality outcomes.

• Participate in and complete structured and mentored training programs; utilize ongoing team support during daily work activities.

• Consistently apply critical thinking and maintain high standards in documentation and decision-making within a structured work environment.

• Exercise independence in fulfilling enterprise expectations and meeting compliance timelines.

• This is a full-time, remote position with a standard schedule of forty hours per week; the role may be performed from any location within the United States.

• 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 related to acute inpatient rehabilitation.

• Board Certified in an approved ABMS or AOA Medical Specialty with continued certification throughout employment.

• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s).

• 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, and acute inpatient rehabilitation.

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

• Utilization management experience in a medical management review organization, such as Medicare Advantage and managed Medicaid.

• Physical Medicine and Rehabilitation, Internal Medicine, Family Practice, Geriatrics, or Hospitalist background

• 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.

Typically reports to a Regional/Associate Vice President, Lead, or Corporate Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May also contribute to grievance and appeals reviews. Some medical directors may join a centralized team for several months after training, until positions become available for specific markets.

May participate on project teams or organizational committees.

This is a fully remote position, applicants must live in the contiguous United States. Occasional travel to Humana's offices for training or meetings may be required.

Typical business hours are Monday-Friday 40 hours per week (start as early as 6am, no later than 9am; some flexibility might be possible,…