Physical Health Medical Director

This is a fully remote position, open to applicants in Illinois, +4 more states.

📋 Description

• Assess whether the requested services, level of care, or site of service should be authorized.

• Make decisions in accordance with regulatory, compliance, clinical guidelines, Medicaid, and CMS standards.

• Develop and sustain knowledge of Medicaid requirements for the designated cluster.

• Conduct computer-based evaluations of moderately complex to highly complex outpatient and inpatient clinical cases.

• Review clinical documentation and supporting records to ensure medical necessity and appropriateness of care.

• Prioritize daily review tasks to fulfill operational and turnaround requirements.

• Communicate determinations and their rationale to internal associates.

• Engage in care management-related activities.

• Conduct peer-to-peer discussions with external physicians via phone.

• Utilize communication and conflict resolution skills during peer-to-peer interactions.

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

• Support initiatives related to value-based care, population health, and disease or care management.

• Uphold Humana’s values and the mission of the Enterprise Social Needs team.

• Provide cross-coverage within the assigned cluster during vacations, weekends, and holidays.

• Report directly to the Cluster Lead Medical Director.

⛳️ Requirements

• Doctor of Medicine or Doctor of Osteopathy degree.

• Board-certified in a specialty recognized by ABMS.

• Current and unrestricted license in at least one state within the specific cluster: IN, OH, KY, VA, WI, or IL.

• Capability to obtain unrestricted licenses in the other states within the cluster that require licensure.

• Experience working with Medicaid enrollees, providers, and stakeholders in clinical or administrative roles.

• Familiarity with accreditation processes, including NCQA.

• Experience with CGX and MHK.

• Background in utilization management review and case management within a health plan environment.

• Availability to work Monday–Friday, 8 hours per day, 5 days a week.

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

• A dedicated workspace free from ongoing interruptions to ensure the protection of member PHI/HIPAA information.

🏝️ 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 and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability coverage.

• Life insurance.

• Occasional travel to Humana offices for training or meetings.