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The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing home health episodic, home health per diem, DME, and waiver requests. 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 Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. 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 works in a structured environment with expectations for consistency in thinking, authorship, meeting departmental expectations, and compliance timelines.

Use your skills to make an impact

Required Qualifications

• MD or DO degree

• 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 license, as required, for various states in region of assignment

• 5+ years of direct clinical patient care experience post residency or fellowship

• No sanctions from Federal or State Governmental organizations

• The ability to pass credentialing requirements

• Excellent verbal and written communication skills with analytic and interpretative skills

• Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution

Preferred Qualifications

• Experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)

• Internal Medicine, Family Practice, Geriatrics, or hospital based clinical specialists

• Ability to function in a dynamic fast paced environment

• Commitment to a culture of innovation

• Passionate about contributing to an organization’s focus on consistency in outcomes, consumer experiences, and a highly engaged team culture

• Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual

The Medical Director conducts clinical case reviews of requests received by members of the Medicare population and reports to the Lead Medical Director.

Other duties:

• Identify medical management operational improvements, including those within the medical director area

• Participate in call rotation

• Develop collaborative relationships with Team and key partners within the Medicare Line of Business.

• Support Home Solutions as needed

• Other activities as assigned by the managing Medical Director

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 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.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.