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Medical Director - Southeast Region - Work from Home at Humana in Boise, Idaho, United States Job Description Become a part of our caring community and help us put health first The Medical Director relies on medical background and reviews health claims.
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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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The curiosity to learn, the flexibility to adapt and the courage to innovate Additional Information 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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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.
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Medical Directors support Humana values, and Humana's Bold Goal mission, throughout all activities. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type.
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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. Job Profile The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested levelof care, and/or requested site of service should be authorized.
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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.
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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. May also engage in grievance and appeals reviews.
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The clinical scenarios predominantly arise from inpatient or post-acute care environments. About us Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company.
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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.
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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.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
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The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it.
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Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work. Use your skills to make an impact 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.
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Physiciancareers Scheduled Weekly Hours 40 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.
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