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Medical Director – OP Medicare
Location
United States
Posted
43 days ago
Salary
$223.8K - $313.1K / year
Seniority
Lead
Job Description
Medical Director – OP Medicare
Humana
• Use clinical expertise, medical judgment, and experience to determine authorization for requested services, level of care, and site of service. • Perform medical necessity reviews in compliance with regulatory standards, CMS requirements, Humana policies, clinical guidelines, and applicable contractual obligations. • Apply knowledge of Medicare and Medicare Advantage requirements in daily utilization management and coverage determination activities. • Conduct computer-based review of moderately complex to complex clinical cases, primarily involving inpatient and post-acute care scenarios. • Review all submitted clinical documentation and records to support accurate, evidence-based determinations. • Interpret whether services rendered by other healthcare professionals align with national guidelines, clinical standards, CMS requirements, and internal policies. • Prioritize daily case review workload to ensure timely completion and adherence to compliance-driven turnaround times. • Communicate utilization review decisions and clinical determinations to internal associates and relevant stakeholders. • Speak regularly with external physicians to obtain additional clinical information, discuss determinations, and support peer-to-peer review processes. • Use conflict resolution skills when needed during physician discussions related to adverse determinations or clinical review outcomes. • Participate in care management activities when applicable to support quality, coordination, and appropriate resource utilization. • Provide oversight or input, as applicable, regarding coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment reviews. • Collaborate with internal team members, cross-functional departments, Humana colleagues, and regional health services leadership to support organizational and market goals. • Engage with contracted physicians, physician groups, facilities, and community organizations to support regional priorities and strengthen collaborative business relationships. • Contribute to initiatives related to value-based care, population health, disease management, and care management strategies. • Work effectively in a structured environment with strong expectations for consistency in clinical reasoning, written determinations, and documentation. • Perform daily responsibilities independently after mentored training, exercising sound judgment with minimal direction. • Meet departmental expectations for quality, consistency, productivity, and compliance timelines.
Job Requirements
- 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).
- Current and ongoing Board Certification in 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
- The curiosity to learn, the flexibility to adapt and the courage to innovate.
Benefits
- 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
- many other opportunities
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