Healthcare Professional

7 days ago

Orlando, Florida, United States Humana Inc Full time
Job Summary

We are seeking a highly skilled Medical Director to join our team at Humana Inc. As a Medical Director, you will play a critical role in ensuring the delivery of high-quality healthcare services to our members.

Key Responsibilities
  • Provide medical interpretation and determinations on services provided by other healthcare professionals to ensure compliance with national guidelines, CMS requirements, and Humana policies.
  • Collaborate with other team members, departments, and Humana colleagues to support the delivery of healthcare services.
  • Conduct utilization management reviews of care received by members in assigned markets, member populations, or condition types.
  • Participate in grievance and appeals reviews, and may engage in project teams or organizational committees.
Requirements
  • MD or DO degree
  • 5+ years of direct clinical patient care experience post residency or fellowship, preferably including experience in an inpatient environment and/or related to care of a Medicare type population.
  • 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 licenses, 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.
Preferred Qualifications
  • Knowledge of the managed care industry, including Medicare Advantage, Managed Medicaid, and/or Commercial products, or other medical management organizations, hospitals/Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
  • Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance.
  • Experience with national guidelines, such as MCG or InterQual.
  • Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists.
  • Advanced degree, such as an MBA, MHA, MPH.
  • Exposure to Public Health, Population Health, analytics, and use of business metrics.
  • Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.
About Humana Inc.

Humana Inc. is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services and CenterWell healthcare services, 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.

Equal Opportunity Employer

Humana is an equal opportunity employer and welcomes applications from diverse candidates. We are committed to creating an inclusive work environment that values diversity, equity, and inclusion.

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