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Clinical Decision Specialist

2 weeks ago


Montpelier, Vermont, United States Humana Full time

Become part of our caring community and help us put health first The Medical Director role relies heavily on medical background and expertise to review health claims and make determinations regarding authorized services, levels of care, and sites of service.

As a Medical Director, you will actively use your medical background, experience, and judgement to make decisions, ensuring compliance with regulatory requirements and utilizing diverse resources such as national clinical guidelines, CMS policies, and clinical reference materials.

Responsibilities 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 will have discussions with external physicians by phone to gather additional information or discuss determinations, and may require conflict resolution skills.

This role requires excellent verbal and written communication skills, evidence of analytic and interpretation skills, and prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning, and/or home health/post-acute services.