Medical Director – National OP, Medicare

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

📋 Description

• Evaluate preauthorization requests for various services.

• Assess whether the requested services, care levels, and/or service sites should receive authorization.

• Examine submitted clinical records and digital clinical scenarios.

• Organize daily tasks and relay decisions to internal team members.

• Engage in care management, grievance and appeals reviews, project teams, or organizational committees as needed.

• Execute Utilization Management for members within a designated market, member population, or condition type.

• Determine if services are in accordance with national guidelines, CMS requirements, Humana policies, clinical standards, and contract specifications.

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

• Interact with external physicians via phone to collect clinical information or discuss decisions.

• Address conflicts that may arise during discussions with physicians when necessary.

• Foster regional market priorities and build collaborative business relationships with external physicians, physician groups, facilities, or community organizations.

• Consistently meet departmental expectations independently.

• Ensure adherence to compliance timelines.

• Typically report to a Regional Vice President of Health Services, Lead, or Corporate Medical Director.

⛳️ Requirements

• MD or DO degree.

• Over 5 years of direct clinical patient care experience following residency or fellowship.

• Ongoing Board Certification in an approved ABMS Medical Specialty.

• Active and unrestricted license in at least one jurisdiction.

• Willingness to acquire additional licensure if necessary.

• No current sanctions from Federal or State Government organizations.

• Capability to meet credentialing criteria.

• Strong verbal and written communication skills.

• Demonstrated analytical and interpretative skills.

• 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 business metrics (preferred).

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

• A dedicated workspace free from interruptions to safeguard member PHI/HIPAA information.

• Home internet service with a minimum of 25 Mbps download and 10 Mbps upload speed.

🏝️ Benefits

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

• Medical, dental, and vision benefits.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays.

• Personal holidays.

• Paid parental leave.

• Paid caregiver leave.

• Short-term disability.

• Long-term disability.

• Life insurance.

• Work-from-home arrangement.

• Potential travel to Humana offices for training or meetings.