Physical Health Medical Director at Humana

, Ohio, United States -

Full Time

Start Date

Immediate

Expiry Date

08 Aug, 26

Salary

313100.0

Posted On

10 May, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Management, Case Management, Medicaid Care Strategy, Clinical Review, Regulatory Compliance, Conflict Resolution, Population Health, Chronic Disease Care Management, Value-based Care, Peer-to-peer Review

Industry

Insurance

Description

Become a part of our caring community The Medical Director is responsible for Medicaid care strategy and/or operations. 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. Position Responsibilities: Uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized. All work occurring within a context of regulatory compliance and assisted by diverse resources, which may include national clinical guidelines, state policies, and CMS policies and determinations. Learns Medicaid requirements and understands how to operationalize this knowledge in their daily work in their assigned cluster. 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. Possible participation in care management, with clinical scenarios arising from outpatient or inpatient environments. Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations. Peer-to-peer process that may require conflict resolution skills. May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities. May include an understanding of Humana processes and a focus on collaborative business relationships, value-based care, population health, and chronic disease care management Supports Humana values and our enterprise social needs team mission throughout all activities. Flows to work as needed within cluster as needed for vacations, weekends and holidays coverage. Use your skills to make an impact Requirements: Doctor of Medicine or Doctor of Osteopathy Board-certified in ABMS or ABOA recognized specialty A current and unrestricted license in at least one of the states that are part of the specific cluster, if required At least five years of experience post-training providing clinical services Experience in utilization management review and case management in a health plan setting No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. Preferred: Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting Experience with accreditation process (NCQA) Experience with CGX and MHK Has licensure through the Interstate Medical Licensure Compact Has a medical license in at least one of the states that are part of the specific cluster Reporting Relationship: This position reports directly to the Cluster Lead Medical Director. Location: This role is based virtually in one of the states of the specific cluster. Work at Home Guidance To ensure Home or Hybrid Home/Office associates have the self-provided internet service you must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested Leadership approves satellite, cellular and microwave connection for use only if they give approval. Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet our requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. 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. $223,800 - $313,100 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 About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. 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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.

Responsibilities

The Medical Director manages Medicaid care strategy and operations, making determinations on requested services and levels of care. This includes conducting clinical reviews and collaborating with external physicians to ensure regulatory compliance.