Medical Director - Southeast 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 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 structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines.
This is a full-time work from home opportunity. Candidates may live anywhere in the US but must be willing to work 8:00am - 5:00pm Eastern time zone and every other weekend with compensated days off during the regular work week.
Use your skills to make an impact
…
This job isn't fresh anymore!
Search Fresh JobsJob Profile
Dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Illinois Montana Remote US South Dakota Work from a dedicated space Work from a dedicated space lacking ongoing interruptions Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Work from Home in the state of California, Illinois, Montana, or South Dakota
Benefits/PerksBonus incentive plan Competitive benefits Dental Health insurance 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
Tasks- Communication
- Communication of decisions
- Compliance
- Documentation
- Medical interpretation
- Medical interpretation and determinations
- Overview of coding practices and clinical documentation
- Participation in care management
- Quality management
- Support regional market priorities
- Training
- Utilization Management
Analytic Analytics BI Business Care management Case Management Clinical Clinical Documentation Clinical Guidelines Clinical Standards CMS policies Coding Coding practices Collaborative Communication Compliance Computer Conflict Resolution Discharge planning Documentation Healthcare Healthcare Professionals Health Insurance Health Services HIPAA InterQual Judgement Leadership Managed Care Medicaid Medical background Medical interpretation Medicare Medicare Advantage National Guidelines Organizational Population health Prioritization Public health Quality Management Recruitment Regulatory Compliance Rehabilitation Social Determinants of Health Teams Training Utilization management Value-based care Verbal and written communication Wellness Written communication
Experience5 years
EducationAdvanced degree Analytics Associates Business Communication DO Education Healthcare Health Services Management MBA M.D. MHA MPH Public health Rehabilitation
CertificationsABMS Medical Specialty Board Certified in an approved ABMS Medical Specialty
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