Medical Director

Become a part of our caring community and help us put health firstBecome a part of our caring community and help us put health first The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, level of care, and/or site of service should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. Weekend work required one weekend per month with compensated days off during the work weekThe Medical Director's work includes reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative professional relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment. Medical Directors support Humana value throughout all activities.ResponsibilitiesThe Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. The ideal candidate enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines.Conduct comprehensive, timely, and compliant medical necessity reviews for inpatient servicesMaintain accountability for productivity, quality, and compliance metricsCommunicate determinations clearly both verbally and in writingDemonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practicesWeekend work required one weekend per month with compensated days off during the work weekUse your skills to make an impactUse your skills to make an impactRequired QualificationsMD or DO degree5+ 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).Current and ongoing Board Certification an approved ABMS Medical SpecialtyA current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required.No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.Excellent verbal and written communication skills.Evidence of analytic and interpretation skills, with prior experience working in a team environmentPreferred QualificationsKnowledge 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, or other healthcare providers.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 InterQualExperience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and hospital-based clinical specialistsThe curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals.Ability to thrive in a dynamic fast-paced, team-oriented environment.Commitment to a culture of innovation, including being facile with using technology to improve workflowsParticipate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contributionPassionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team cultureAdditional InformationThe medical director reports to a Lead Medical Director.Participation in weekend work on a rotational basis to ensure cases are decisioned in a timely mannerMay participate on project teams or organizational committees.physiciancareersTravel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours40Pay RangeThe compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$223,800 - $313,100 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.Application Deadline: About usHumana Inc. (NYSE: HUM) 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. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.Equal Opportunity EmployerIt is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.