Become a part of our caring community and help us put health firstHumana Healthy Horizons is seeking a Medical Director to provide medical interpretations and determinations on 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 of Health Services.The Medical Director reports to the Lead Medical Director for the Southeast Medicaid Markets. In this role, the Medical Director actively uses a 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.Key Roles, Objectives, and Responsibilities include:
Gain knowledge of the Southeast region state Medicaid requirements (currently FL and SC) and understand how to operationalize this knowledge in daily work.
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).
Meet with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills.
The role includes an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within the respective scope.
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.
Conduct Utilization Management of the care received by members in the FL and SC Medicaid market populations.
May provide cross-coverage for other state Medicaid markets, as well as participate on project teams or organizational committees.
After completion of mentored training, daily work is performed with minimal direction and will exercise independence in meeting departmental expectations.
Work in a structured environment with expectations for consistency in thinking, authorship, and meeting compliance timelines.
Occasional limited weekends required.
All other duties as assigned.
Use your skills to make an impactRequired Qualifications
MD or DO degree.
5+ years of direct clinical patient care experience post residency or fellowship.
Current and ongoing Board Certification in an approved ABMS Medical Specialty.
A current and unrestricted Florida license and willing to obtain additional license(s).
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, with prior experience participating in teams focusing on 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.
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.
Work at Home Requirements
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Additional Information
Travel : None.
Workstyle: Remote, must work hours within the eastern time zone.
Core Workdays & Hours: Typically, 8-5 pm Monday - Friday; Eastern Standard Time (EST) with occasional weekends required.
Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more
Interview FormatAs part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.Scheduled Weekly Hours40Pay RangeThe 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 yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.About usHumana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.Equal Opportunity EmployerIt is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=HumanaWebsite.
