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 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.
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.
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 ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines. Supports the assigned work with respect to market-wide objectives (e.g. Bold Goal) and community relations as directed.
- 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(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).
- 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
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 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.