• The Medical Director relies on medical background and reviews health claims
• The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors
• 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 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

• 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 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 mentored training, daily work is performed with minimal direction
• Enjoys working in a structured environment with expectations for consistency in thinking and authorship
• Exercises independence in meeting departmental expectations, and meets compliance timelines
• Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business
• The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type
• May also engage in grievance and appeals reviews
• May participate on project teams or organizational committees
• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required

Scheduled Weekly Hours

• MD or DO degree
• 4 x 10h (Fri, Sat, Sun, Mon)
• 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
• Current and ongoing Board Certification an approved ABMS Medical Specialty
• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
• 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

• The 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 $223,800 - $313,100 per year

• This job is eligible for a bonus incentive plan
• This incentive opportunity is based upon company and/or individual performance
• Humana, 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