Medical Director--Claims Management

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 at the Appeals/Disputes level.
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.
Responsibilities 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.
Required Qualifications MD or DO degree 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).
Board Certified in an approved ABMS Medical Specialty with continued certification throughout employment.
A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), 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) Preferred Qualifications Understands Medicare Outpatient Guidelines Understands Medicare Inpatient Guidelines Knowledge of Medicare Appeals 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 Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialization Advanced degree such as an MBA, MHA, or MPH Exposure to Public Health principles, 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 Additional Information Typically reports to a Director 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.
Some medical directors may join a centralized team for several months after training, until positions become available for specific markets.
May participate on project teams or organizational committees.
Work at Home Guidance To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: 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 Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
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 This is a remote position #LI-Remote Scheduled Weekly Hours 40 Pay Range 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 decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$199,400 - $274,400 per year This job is eligible for a bonus incentive plan.
This incentive opportunity is based upon company and/or individual performance.
Description of Benefits 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.
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