Commercial Medical Director - Work At Home

Profile

Description

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, Humana contract language, Humana coverage policies and determinations, MCG, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Commercial requirements and will understand how to operationalize this knowledge in their daily work.

Responsibilities

Title: Commercial Medical Director

Location: Work At Home - any state

Schedule: 40 hours per week, with rotating weekend call - on average every 6 weeks.

Job Summary

The Medical Director's work includes computer-based review of moderately 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, post-acute care environments, outpatient service requests, ER review, pharmacy review work, and sometimes appeals review. The Medical Director 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.

Responsibilities

The Commercial Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, state mandates, contract language, Humana policies and MCG. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Healthcare Clinical Operations. After completion of structured and mentored training, daily work is performed with minimal direction but with ready support from other team members. The Medical Director enjoys working in a structured environment with expectations for consistency in thinking and authorship, exercises independence in meeting departmental expectations and meets compliance timelines. Medical Director supports the assigned work with respect to market-wide objectives (e.g. Bold Goal) and community relations as directed.

Makes determinations regarding prior authorization and retrospective reviews for inpatient and outpatient services

Performs concurrent stay reviews for inpatient services, including rounds with case management teams

Makes determinations regarding prior authorization review for pharmacy cases

Performs Peer to Peer consultation as needed during review process or upon request of the attending physician

Participates in HCO MD Inter-Rater Reliability (IRR) testing, annually

Participates in Clinical Policy Development forum (TAF)

Collaborates with physician, clinical and market leaders to identify opportunities to improve health care and health care delivery

Collaborates with Clinical Learning and Development to create clinical training and educational materials

Engages with key internal stakeholders that provide services and support to Humana and/or directly to customers

Participates in corporate-wide committees

Performs quality reviews

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 Commercial patients

Current and ongoing active Board Certification in an approved ABMS Medical Specialty

A current and unrestricted state license

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

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 or sub specialty, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialization

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

Will report to a Lead Medical Director. The Medical Director conducts Utilization Management of the care received by members in an assigned line of business, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees.

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Scheduled Weekly Hours

40

Company info

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