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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. The clinical scenarios predominantly arise from inpatient or post-acute care environments.
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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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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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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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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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Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. 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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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.
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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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May also engage in grievance and appeals reviews. About us Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. 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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Current/unrestricted Licensed Clinical Social Worker (LCSW) or Licensed Professional Counselor (LPC) or Licensed Mental Health Counselors (LMHC) (or state equivalent) or Current Licensed Marriage and Family Therapists (LMFT only in CA.
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An active, independent Florida Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Counselor (LPC) We're seeking therapists who are truly passionate about delivering individual, family and couples psychotherapy, with a commitment to client-centered care and a deep understanding of trauma-informed approaches and evidence-based practices.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. 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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An active, independent California Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Clinical Psychologist.
$68,000 - $100,000 a yearFull-timeRemoteExpandApply NowActive JobUpdated Today
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