Medical Director - PRN at Humana

**Become a part of our caring community and help us put health first**

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, participation in care management and possible participation in care facilitation with hospitals. The clinical scenarios predominantly arise from inpatient or post-acute care environments. There are 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. An aspect of the role includes 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 care facilitation and 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. Medical Directors support Humana values, and Humana's Bold Goal mission, throughout all activities.

Responsibilities

The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines.

**Use your skills to make an impact**

**Required Qualifications**

• 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 as well as ABQAURP, or other board demonstrating advanced training in transitions of care, quality assurance, utilization management and care coordination
• 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 organizational, verbal and written communication skills.
• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on transitions of care, quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation.
  
  

Preferred Qualifications

• Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
• 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
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists
• Advanced degree such as an MBA, MHA, MPH
• Exposure to value based care, 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
  
  

**Additional Information**

Additional Information

Will report to the Director of Physician Leadership in Population Health Strategy at Primary Care Organization. The Medical Director conducts Utilization Management of the care received by members in an assigned region, market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees.

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**Scheduled Weekly Hours**

1

**Pay Range**

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$199,400 - $274,400 per year

**Description of Benefits**

Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers benefits for limited term, variable schedule and per diem associates which are designed to support whole-person well-being. Among these benefits, Humana provides paid time off, 401(k) retirement savings plan, employee assistance program, business travel and accident.

**About us**

About Conviva: Conviva Care Centers provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of Humana's Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health - addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being. About Humana: Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our cus

Compensation Information

$199400.0 / Yearly - $199400.0 / Yearly

Starting At: 199400.0 Yearly

Up To: 274400.0 Yearly