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Medical Director Position

1 week ago


Providence, Rhode Island, United States Humana Full time
About the Job:
Humana is seeking a skilled Medical Director to lead our healthcare decisions. This role requires a medical background and expertise in reviewing health claims. The ideal candidate will have experience working with moderately complex to complex issues, where analysis of situations or data requires in-depth evaluation of variable factors.

In this position, you will rely on your medical background and judgment to make determinations about requested services, level of care, and site of service. You will work within a context of regulatory compliance, using diverse resources such as national clinical guidelines, CMS policies, and clinical reference materials. As a Medical Director, you will learn Medicare and Medicare Advantage requirements and operationalize this knowledge in your daily work.

Your responsibilities will include computer-based review of clinical scenarios, review of submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. You may also engage in grievance and appeals reviews and participate on project teams or organizational committees.

Required Skills and Qualifications:
- MD or DO degree
- 5+ years of direct clinical patient care experience post-residency or fellowship
- Current and ongoing Board Certification in an approved ABMS Medical Specialty
- A current and unrestricted license in at least one jurisdiction and willingness to obtain additional license if required
- No current sanction from Federal or State Governmental organizations and ability 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

Benefits:
Humana offers competitive benefits that support whole-person well-being, including medical, dental, and vision benefits, 401(k) retirement savings plan, time off, short-term and long-term disability, life insurance, and many other opportunities.