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Humana

Louisville, Kentucky-based Humana is a leading healthcare company that offers a variety of health, wellness, and insurance products and services designed to off

Medical Director – Southeast Medicaid

Location

Florida

Posted

115 days ago

Salary

$223.8K - $313.1K / year

Seniority

Lead

Postgraduate Degree5 yrs expEnglish

Job Description

Medical Director – Southeast Medicaid

Humana

• Rely on medical background and review health claims • Work assignments involve moderately complex to complex issues where analysis requires in-depth evaluation of variable factors • Make determinations whether to authorize requested services, request level of care, and requested site of service • Conduct Utilization Management of the care received by members in an assigned market, member population, or condition type • Participate in care management and discussions with external physicians • Review clinical records, prioritize daily work, and communicate decisions • Support regional market priorities, which may include understanding Humana processes

Job Requirements

  • MD or DO degree
  • 5+ years of direct clinical patient care experience post residency or fellowship
  • Current and ongoing Board Certification in an approved ABMS/AOA Medical Specialty
  • No current sanction from Federal or State Governmental organizations, able to pass credentialing requirements
  • Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and home health or post-acute services
  • Managed Medicaid or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management
  • A current and unrestricted license in Florida
  • Willing to obtain licensure in South Carolina and Georgia
  • 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
  • Exposure to Public Health, 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.

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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