Medical Director National OP, Medicare

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The Medical Director relies on medical background and reviews preauthorization requests for services. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs with 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 sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.

The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.

The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value-based care, population health, or disease or care management.

Use your skills to make an impact

Responsibilities

• Provide medical interpretation and determine whether services delivered by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and contract requirements, when applicable
• Support and collaborate with team members, other departments, Humana colleagues, and The Regional VP, Health Services
• Perform daily responsibilities with minimal direction after completing mentored training
• Work effectively in a structured environment with expectations for consistency in clinical thinking, written determinations/authorship
• Exercise independence in meeting departmental expectations
• Ensure compliance timelines are consistently met

• MD or DO degree
• 5+ 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 in an approved ABMS Medical Specialty
• A 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
• The curiosity to learn, the flexibility to adapt and the courage to innovate.
• The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type.
• May also engage in grievance and appeals reviews.
• May participate on project teams or organizational committees.

• Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid.
• 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 InterQual
• Advanced degree such as an MBA, MHA, MPH
• Exposure to Public Health, Population Health, analytics, and use of business metrics.
• Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.
• The curiosity to learn, the flexibility to adapt and the courage to innovate