Medical Director – OP Medicare

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

📋 Description

• Assess preauthorization requests for services, care levels, and service locations.

• Execute medical necessity and coverage evaluations based on CMS policies, Medicare and Medicare Advantage guidelines, clinical criteria, Humana policies, and contractual obligations.

• Conduct computer-based reviews of moderately complex to intricate outpatient clinical cases.

• Analyze submitted clinical documentation and records to make precise, evidence-based decisions.

• Determine if healthcare services comply with national guidelines, clinical standards, CMS requirements, and internal policies.

• Organize and manage daily case review workload to adhere to compliance-driven turnaround times.

• Communicate utilization review outcomes and clinical decisions to internal associates and pertinent stakeholders.

• Collaborate with external physicians to gather further clinical information, discuss determinations, facilitate peer-to-peer reviews, and resolve disputes during adverse determination discussions.

• Engage in care management activities to promote quality outcomes, care coordination, and appropriate resource utilization.

• Offer oversight or input on coding practices, clinical documentation, grievance and appeals processes, and reviews of outpatient services and equipment.

• Partner with internal teams, cross-functional partners, Humana colleagues, and regional health services leadership.

• Interact with contracted physicians, physician groups, facilities, and community organizations.

• Contribute to value-based care, population health, disease management, and care management initiatives.

• Operate independently following mentored training while achieving quality, productivity, documentation, and compliance standards.

• Take part in grievance and appeals reviews, project teams, and organizational committees as needed.

⛳️ Requirements

• MD or DO degree.

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

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

• Active and unrestricted license in at least one jurisdiction.

• Willingness to obtain additional licenses if required.

• No current sanctions from Federal or State Government entities.

• Ability to meet credentialing requirements.

• Excellent verbal and written communication abilities.

• Proven analytical and interpretive skills.

• Capacity to evaluate information and make informed decisions.

• Understanding of the managed care industry, including Medicare Advantage and Managed Medicaid.

• Prior utilization management experience in a medical management review organization is preferred.

• Familiarity with national clinical guidelines such as MCG or InterQual is preferred.

• An advanced degree such as an MBA, MHA, or MPH is preferred.

• Exposure to Public Health, Population Health, analytics, and business metrics is preferred.

• Experience working collaboratively with Case Managers or Care Managers on complex case management is preferred.

• Awareness of social determinants of health is preferred.

• Ability to work Monday through Friday during standard business hours, 8 hours per day, 5 days per week.

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

• Capability to work from a designated space free from ongoing interruptions to safeguard PHI/HIPAA information.

🏝️ Benefits

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

• Medical benefits.

• Dental benefits.

• 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.

• Remote work arrangement.

• Occasional travel to Humana offices for training or meetings.

• Dedicated home workspace and internet requirements for remote work.