Medical Director - Northeast Region - Remote US
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 within 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 reference sources. 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. 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 …
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Regions Countries Benefits/Perks401(k) retirement savings plan Bonus incentive plan Competitive benefits Dental Life Insurance Medical Paid parental and caregiver leave Paid Time Off Parental and Caregiver Leave Personal holidays Time off Vision Vision Benefits Volunteer time Volunteer time off
SkillsAnalytic Analytics Business Care management Case Management Clinical Documentation Clinical Standards Coding Coding practices Communication Compliance Computer Conflict Resolution Discharge planning Documentation Healthcare Health Insurance Health Services HIPAA InterQual Leadership Managed Care Medicaid Medical background Medical interpretation Medicare National Guidelines Organizational Population health Prioritization Public health Quality Management Regulatory Compliance Rehabilitation Social Determinants of Health Teams Utilization management Verbal and written communication Wellness Written communication
Tasks- Communication of decisions
- Compliance
- Documentation
- Medical interpretation
- Support regional market priorities
- Training
5 years
EducationAdvanced degree Analytics Associates Business Communication DO MBA M.D.
Certifications RestrictionsRemote US Work from a dedicated space Work from a dedicated space lacking ongoing interruptions
TimezonesAmerica/Anchorage America/Chicago America/Denver America/Los_Angeles America/New_York Pacific/Honolulu UTC-10 UTC-5 UTC-6 UTC-7 UTC-8 UTC-9