Medical Director Lead

6 days ago

Lincoln, Nebraska, United States Humana Full time
Humana Medical Director - National Medicare Team

Become a part of our caring community and help us put health first by working as a clinical decision specialist. This role requires medical background expertise to review preauthorization requests for services, handling moderately complex to complex issues where analysis of situations or data necessitates in-depth evaluation of variable factors.

The ideal candidate will provide medical interpretation and determinations whether services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, and clinical standards. Primary work responsibilities include reviewing prior-authorization reviews as well as some claims and provider dispute cases for outpatient reviews.

Responsibilities:

  1. Provide medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, and clinical standards.
  2. Support and collaborate with other team members, departments, and Humana colleagues to achieve shared goals.
  3. After completion of mentored training, daily work is performed with minimal direction, exercising independence in meeting departmental expectations and compliance timelines.
  4. Enjoys working in a structured environment with expectations for consistency in thinking and authorship.
  5. Exercises independence in meeting departmental expectations, and meets compliance timelines.
  6. Supports assigned work with respect to market-wide objectives and community relations as directed.
  7. May participate on project teams or organizational committees.

Requirements:

  1. MD or DO degree.
  2. 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).
  3. Current and ongoing Board Certification in an approved ABMS Medical Specialty.
  4. A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required.
  5. No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
  6. Excellent verbal and written communication skills.
  7. Evidence of analytic and interpretation skills.
  8. The curiosity to learn, the flexibility to adapt, and the courage to innovate.

About the Role:

This utilization review director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May participate on project teams or organizational committees.

Benefits:

  • Competitive salary range: $223,800 - $313,100 per year.
  • This job is eligible for a bonus incentive plan based upon company and/or individual performance.
  • Comprehensive benefits package including medical, dental, vision benefits, 401(k) retirement savings plan, time off, short-term and long-term disability, life insurance, and more.

About Us:

Humana Inc. is committed to putting health first – for our teammates, our customers, and our company. We make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it.

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