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. Candidates must live in one the following states: New York, New Jersey, Vermont, Maine, Massachusetts, Connecticut, Rhode Island or New Hampshire.
Responsibilities
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. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
Responsibilities
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 mentored training, daily work is performed with minimal direction. 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.
Periodically presents talks on clinical topics, clinical practice guidelines and/or case presentations to the regional Health Services Organization team.
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.
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.
Preferred Qualifications
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 specialists
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
Location in Northeast Region (New York, New Jersey and New England)
Additional Information
Will report to the Regional Vice President for Health Services, Northeast Region. 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. May participate on project teams or organizational committees with opportunities for involvement in regional or corporate projects and initiatives, when time permits.
Employer job 
90 Day Old Job 
