Medical Director - Outpatient Medicare

About this role

Become a part of our caring community   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.

Use your skills to make an impact   Responsibilities • Review health claims and clinical documentation to evaluate moderately complex to complex cases requiring medical judgment and in-depth analysis.

• Determine medical necessity and make authorization decisions regarding requested services, level of care, and site of service.

• Conduct computer-based reviews of clinical scenarios, primarily involving inpatient and post-acute care settings.

• Assess submitted medical records against national clinical guidelines, CMS policies and determinations, clinical reference materials, and internal policies.

• Apply Medicare and Medicare Advantage requirements accurately and operationalize this knowledge in daily utilization management decisions.

• Prioritize daily case reviews and ensure timely, accurate communication of determinations to internal associates and stakeholders.

• Engage in peer-to-peer discussions with external physicians to obtain additional clinical information, clarify treatment plans, and discuss authorization decisions.

• Use professional judgment and conflict resolution skills when handling complex or disputed clinical determinations.

• Provide medical interpretation to confirm whether services delivered by healthcare professionals align with clinical standards, regulatory requirements, Humana policies, and applicable contracts.

• Support grievance and appeals reviews, and in some roles, contribute oversight related to coding practices, clinical documentation, outpatient services, and durable medical equipment.

• Collaborate with care management, cross-functional teams, regional leadership, and other Humana departments to support compliance, consistency, and business priorities.

• Build and maintain productive relationships with contracted physicians, physician groups, facilities, and community partners in support of value-based care, population health, and regional market initiatives.

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).

• 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.

• Professional, prompt 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 • The following medical specialties: pulmonology, sleep medicine, cardiology, general surgery, radiology, interventional radiology, and genetics.

• Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid.

• 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

• Advanced degree such as an MBA, MHA, MPH

• 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.

• The curiosity to learn, the flexibility to adapt and the courage to innovate

Additional Information 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 me

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