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DescriptionThe Vendor Quality Medical Director will manage clinical vendor quality outcomes for Humana Clinical Operations Team.ResponsibilitiesA full time Medical Director to manage clinical vendor quality outcomes for Humana Clinical Operations Team. The duties include designing data dashboards with track and trending quality KPIs and improving outcomes to our membership. Monthly meetings and ad hoc meetings would be required with our vendor clinical team to review quality audit findings, medical necessity determinations and patient outcome data.Knowledge in Medicare CMS criteria for inpatient and outpatient utilization management is required with understanding of the Medicare Appeals process. Previous experience with developing data tracking tools and delivering quality outcomes for insurance members, having demonstrated interactions and alignment with data scientists and various data platforms (PowerBi, Excel). Familiarity with operational process mapping and how it applies to prior authorizations and concurrent medical requests is desired.Desired candidate will need to align closely with the vendor management team, clinical risk team and physician auditing team to review clinical decisions align with CMS guidance. Provide feedback for the enterprise partners and train/teach concepts to reviewing medical directors.Requirements:Board Certified in Recognized United States Medicine Specialty
Medicare Utilization Management Experience at least 2 years
Unrestricted Medical License in any one of the US States
Practice in the office and/or hospital setting for at least 5 years
Knowledge of Medicare CMS Insurance, ideally in the inpatient and outpatient section. Knowing how to look up coverage determinations, regulations, and criteria to apply appropriately in a compliant process.
Desired:Masters in Medical Management or Business Administration
Location:Work from home, 100%
Scheduled Weekly Hours40
