Medical Director - Florida

Humana Medical Director - Florida

Become a part of our caring community and help us put health first

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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.

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 with 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 sources of expertise.

Use your skills to make an impact

Responsibilities

• The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts.
• The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services.
• After completion of mentored training, daily work is performed with minimal direction.
• Enjoys working in a structured environment with expectations for consistency in thinking and authorship.
• Exercises independence in meeting departmental expectations, and meets compliance timelines.
• Supports the assigned work with respect to market-wide objectives (e.g. Bold Goal) and community relations as directed.

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).

• 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, 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.

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 specialists.
• Advanced degree such as an MBA, MHA, MPH.
• Exposure to Public Health, 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.

Scheduled Weekly Hours

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.

$199,400 - $274,400 per year. This job is eligible for a bonus incentive plan.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being.

About us

Humana Inc. (NYSE : HUM) is committed to putting health first - for our teammates, our customers and our company.

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 veteran status.

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