Medical Director - Texas

Profile

Job Information

Humana

Medical Director - Texas

in

Vancouver

Washington

Description

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.

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.

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).

Board Certified in an approved ABMS Medical Specialty with continued certification throughout employment

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).

Must have accessibility to high speed DSL or cable modem for a home office (satellite internet service is NOT allowed for this role); and a minimum internet connection speed of 10M x 1M

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 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

Additional Information

For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.

If progressed to offer, you will be required to:

Provide proof of full vaccination or commit to testing protocols

*OR  *

Provide proof of applicable exemption including any required supporting documentation

Medical, religious, state and remote-only work exemptions are available.

The Medical Director conducts clinical reviews of the care received by members in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews and/or condition committees. Must hold a MD or DO and be board certified and typically reports to a Lead or Regional or Corporate Medical Director, depending on size of region/line of business. No direct supervisory responsibility is expected though it may occur or the Medical

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com