Medical Director – Medicaid
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Job Description
Medical Director overseeing healthcare compliance and clinical determinations for Humana. Utilizing medical expertise to review health claims and collaborate with other healthcare professionals while working remotely.
Responsibilities:
- 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 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.
- Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly.
- 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 to support regional market priorities.
Requirements:
- MD or DO degree
- OK and LA licenses, or ability to obtain
- 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 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.
Benefits:
- medical, dental and vision benefits
- 401(k) retirement savings plan
- time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
- short-term and long-term disability
- life insurance and many other opportunities
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