Physical Health Medical Director
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Job Description
Medical Director guiding Medicaid utilization decisions for Humana’s insurance and healthcare services. Reviewing complex clinical cases and authorizing medically necessary care remotely.
Responsibilities:
- Determine whether requested services, level of care, or site of service should be authorized
- Make determinations according to regulatory, compliance, clinical guideline, Medicaid, and CMS requirements
- Develop and maintain knowledge of Medicaid requirements for the assigned cluster
- Perform computer-based reviews of moderately complex to highly complex outpatient and inpatient clinical cases
- Review clinical documentation and supporting records for medical necessity and appropriateness of care
- Prioritize daily review work to meet operational and turnaround requirements
- Communicate determinations and rationale to internal associates
- Participate in care management-related activities
- Conduct peer-to-peer discussions with external physicians by phone
- Apply communication and conflict resolution skills during peer-to-peer conversations
- Collaborate with contracted physicians, physician groups, facilities, and community organizations
- Support value-based care, population health, and disease or care management initiatives
- Support Humana’s values and the Enterprise Social Needs team mission
- Provide cross-coverage across the assigned cluster for vacations, weekends, and holidays
- Report directly to the Cluster Lead Medical Director
Requirements:
- Doctor of Medicine or Doctor of Osteopathy
- Board-certified in an ABMS recognized specialty
- Current and unrestricted license in at least one state in the specific cluster: IN, OH, KY, VA, WI, or IL
- Ability to obtain unrestricted licenses in the other cluster states that require licensure
- Experience working with Medicaid enrollees, providers, and stakeholders in a clinical or administrative setting
- Experience with accreditation processes, including NCQA
- Experience with CGX and MHK
- Experience in utilization management review and case management in a health plan setting
- Ability to work Monday–Friday, 8 hours/day, 5 days/week
- Minimum home internet speed of 25 Mbps download and 10 Mbps upload
- Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information
Benefits:
- Bonus incentive plan based on company and/or individual performance
- Medical, dental and vision benefits
- 401(k) retirement savings plan
- Paid time off
- Company and personal holidays
- Paid parental and caregiver leave
- Short-term and long-term disability
- Life insurance
- Occasional travel to Humana offices for training or meetings
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