National Medicaid Medial Director - Long Term Services & Supports (LTSS)

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 The Medical Director’s primary responsibility is the review of medical authorizations to determine the medical necessity of a given service, level of care, or medical item/supply. The Medical Director’s work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors that rely on clinical experience and knowledge of both medicine and social determinants of health.

The LTSS (Long Term Services & Supports) Reviewing Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, requested site of service, and/or medical supply 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, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Director will learn National LTSS State Medicaid requirements (currently FL; IN; and other states as needed) and understand how to operationalize this knowledge into their daily work.

 

The LTSS (Long Term Services & Supports) Reviewing 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, Grievance & Appeal reviews, participation in ICT’s (Intra Collaborative Team meetings); and attend Fair Hearings. The clinical scenarios arise from outpatient, post-acute care; acute inpatient; LTC (Long Term Care); and HCBS (home and community based services) environments. Reviews include, but not limited to, home health services, therapy services, consumable medical supplies (CMS); home or vehicle modifications, and durable medical equipment (DME).

 

Other duties include, but may not be limited to, an overview of clinical documentation, Letter of Agreements, coding practices, Clinical Integration, Long Term Services & Supports services, and Case Management. The Medical Director, as indicated, could need to have discussions with external physicians, providers, Care Coaches, and UM Team associates by phone or internal messaging to gather additional clinical information or discuss determinations, and in some instances these discussions may require conflict resolution skills.

 

The LTSS (Long Term Services & Supports) Reviewing Medical Director may occasionally speak with contracted external physicians, provider groups, health care facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a …