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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.
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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.
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Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and General Surgery clinical specialists. The Corporate Medical Director relies on medical background and reviews health claims and preservice appeals.
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Partner with clinical team to ensure quality deliverables designed to oversee patient intake and inquiries and assess patient needs. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.
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The Medical Director conducts clinical case reviews of requests received by members of the Medicare population and reports to the Lead Medical Director. The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing skilled nursing facility requests.
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Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. The clinical scenarios predominantly arise from inpatient or post-acute care environments.
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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.
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Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialization. Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business.
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Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists. 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.
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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.
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The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. The Medical Director's 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, and possible participation in care management.
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The Associate Vice President (AVP), Stars and Risk Adjustment National Medical Director leads key strategic and operational functions. AVP, Stars and Risk Adjustment National Medical Director.
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The Corporate 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.
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Internal Medicine, Family Practice, Geriatrics, or hospital based clinical specialists. 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.
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5+ years of direct clinical patient care experience post residency or fellowship. 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.
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clinical director jobs Title: director Company: Humana
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