Medical Director - Mid West Region (Columbia)

Medical Director Opportunity

Become a part of our caring community and help us put health first. The Medical Director actively uses their medical background, experience, and judgment to make determinations whether requested services, level of care, and / or 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, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. The Medical Director's work includes reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative business relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment. Medical Directors support Humana value throughout all activities.

Responsibilities :

• Provide medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts.
• Support and collaborate with other team members, other departments, Humana colleagues and the Regional VP Health Services.
• After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members.
• Enjoy working in a structured environment with expectations for consistency in thinking and authorship.
• Exercises independence in meeting departmental expectations and meets compliance timelines.

Required Qualifications :

65 years of age)

Preferred Qualifications :

Additional Information :