Medical Director – National OP Medicare

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate preauthorization requests for various services.

• Make decisions regarding the requested services, levels of care, and service locations.

• Analyze clinical records and intricate clinical scenarios utilizing national clinical guidelines, CMS policies, clinical references, and Humana policies.

• Prioritize daily tasks related to computer-based reviews.

• Communicate decisions to internal team members.

• Engage in care management when applicable.

• Discuss cases and decisions with external physicians via phone.

• Collect additional clinical information and resolve any conflicts when necessary.

• Assess coding practices, clinical documentation, grievance and appeals processes, outpatient services, and equipment within the scope of work.

• Support regional market objectives by interacting with external physicians, physician groups, facilities, or community organizations.

• Provide medical interpretation and make determinations for healthcare services.

• Collaborate with team members, departments, Humana colleagues, and the Regional VP of Health Services.

• Complete mentored training and execute daily tasks with minimal supervision.

• Meet departmental expectations, compliance deadlines, and standards of consistency.

• Conduct utilization management for members within a designated market, population, or condition type.

• Participate in grievance and appeals reviews, project teams, or organizational committees.

⛳️ Requirements

• MD or DO degree.

• 5+ years of direct clinical patient care experience after residency or fellowship.

• Current and ongoing Board Certification in an approved ABMS/AOA Medical Specialty.

• Current and unrestricted license in at least one jurisdiction.

• Willingness to obtain additional licenses if necessary.

• No existing sanctions from Federal or State Governmental entities.

• Ability to fulfill credentialing requirements.

• Outstanding verbal and written communication skills.

• Demonstrated analytical and interpretative abilities.

• Familiarity with the managed care industry, including Medicare Advantage and Managed Medicaid (preferred).

• Experience in utilization management within a medical management review organization (preferred).

• Knowledge of national guidelines such as MCG® or InterQual (preferred).

• Advanced degree such as an MBA, MHA, or MPH (preferred).

• Exposure to Public Health, Population Health, analytics, and the use of business metrics (preferred).

• Experience collaborating with Case Managers or Care Managers on complex case management, including awareness of social determinants of health (preferred).

• Minimum home internet speeds of 25 Mbps download and 10 Mbps upload.

• Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information.

🏝️ Benefits

• Bonus incentive plan based on company and/or individual performance.

• Medical, dental, and vision coverage.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability coverage.

• Life insurance.

• Work-from-home arrangement.

• Occasional travel to Humana offices for training or meetings.

• Dedicated workspace and internet requirements to facilitate remote work.