Join our compassionate community dedicated to prioritizing health! The Medical Director plays a vital role in reviewing and determining the authorization of requested services and levels of care. This position operates under strict regulatory compliance while utilizing a range of resources including national clinical guidelines, CMS policies, and internal clinical references. As part of this role, you'll gain a comprehensive understanding of Medicare and Medicare Advantage requirements and learn to apply this knowledge effectively in your day-to-day responsibilities. In this position, you will be responsible for analyzing submitted medical records, navigating complex clinical situations typical of hospital environments, and providing expert decisions on service requests. Regular communication with external providers to gather additional clinical data is integral to your role. Collaborating effectively with your team and embodying Humana's values is essential for success. Key Responsibilities: Conduct thorough, timely, and compliant medical necessity reviews for inpatient services. Be accountable for meeting productivity, quality, and compliance objectives. Clearly communicate determinations both verbally and in writing. Participate in weekend rotations and occasional holiday duties. Exhibit adaptability and eagerness to learn new workflows and utilization management practices. Work Schedule: Monday - Friday with standard weekends (approximately 5 per year), Eastern Time Zone hours. Required Qualifications: MD or DO degree. 5 years of direct clinical patient care experience post residency or fellowship, preferably in inpatient settings, and/or care for Medicare populations. Current and active Board Certification in a recognized ABMS Medical Specialty. A current and unrestricted medical license in at least one jurisdiction, with willingness to obtain additional licenses as necessary. Free from current sanctions by Federal or State governmental organizations and able to meet credentialing standards. Strong verbal and written communication skills. Demonstrated analytical and interpretation abilities, with experience in a collaborative team environment. Preferred Qualifications: Familiarity with managed care concepts, including Medicare Advantage and Managed Medicaid. Experience in utilization management within a medical management review organization. Knowledge of national guidelines such as MCG® or InterQual. Experience in hospital-based clinical practice, including specialties like Internal Medicine, Family Practice, Geriatrics, Hospitalist, or Emergency Medicine. A willingness to learn and adapt to enhance productivity and organizational goals. Ability to thrive in a dynamic, fast-paced, team-oriented environment. Commitment to innovation and utilizing technology to streamline workflows. Engagement in educational activities and content creation for training and presentations. Passion for contributing to an organizational culture focused on consistent outcomes and a highly engaged team. Additional Information: The Medical Director reports to a Lead Medical Director and may participate in project teams or organizational committees. Participation in weekend work on a rotational basis is required to ensure timely case decisions. While this is a remote role, occasional travel to Humana offices for training or meetings may be necessary. Scheduled Weekly Hours: 40 Compensation: The estimated annual base salary ranges from $223,800 to $313,100, depending on geographic location, skills, and experience. This position is also eligible for a bonus incentive plan based on performance. About Humana: Humana Inc. is dedicated to putting health first for our teammates, customers, and communities. With our insurance services and healthcare solutions, we strive to improve the quality of life for individuals across various demographics. Equal Opportunity Employer: Humana promotes equal employment opportunities and does not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status.
