Humana Reviewing Medical Director - Work at Home in Louisville, Kentucky
Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana’s Perfect Service® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.
Be a part of our Clinical Operations team that’s dedicated to improving the health and well-being of our members, our associates, the communities we serve, and our planet.
Humana is seeking a Clinical Innovations Medical Director that will collaborate with other health care givers in reviewing actual and proposed medical care services against established CMS, DOI, Humana and other nationally recognized and accepted guidelines.
- Provide physician review services for utilization management, case management, quality management, and conduct peer to peer reviews
- Develop, maintain and assure compliance with physician review policies and procedures (including timeliness) for utilization management and support case management
- Support collaborative relationships with physicians, large provider groups, hospitals, other facilities and ancillary providers
- Examine clinical programs information to identify members for specific case management and/or disease management activities or interventions by utilizing established screening criteria
Conduct admission review, post-discharge and discharge planning with clinical staff and peers Key Competencies
Interpersonal Effectiveness: Understands oneself, effectively manages emotions, listens and communicates with respect, and builds trusting relationships.
- Accountability: Meets established expectations and takes responsibility for achieving results; encourages others to do the same.
- Collaborates: Engages others by gathering multiple views and being open to diverse perspectives, focusing on a shared purpose that puts Humana's overall success first.
- Executes for Results: Effectively leverages resources to create exceptional outcomes, embraces change, and constructively resolves barriers and constraints.
- Board Certified MD/DO in a ABMS Medical Specialty with an active unrestricted license and the willingness to obtain additional licenses as requested;
- Excellent communication skills with 5 years of established clinical experience
- Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
- Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning and/or home health or rehab.
- Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
- Internal Medicine, Family Practice, Geriatrics, Hospitalist clinical specialists.
- Previous Medicare, Medicaid, and/or Commercial experience.
You will report to a Regional Medical Director. This area is under the leadership of the SVP & Division President.
At Humana, we know your well-being is important to you, and it’s important to us too. That’s why we’re committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. If you share our passion for helping people, we likely have the right place for you at Humana.
After applying, we encourage you to join our Talent Network as well, so you can stay informed and up to date on what’s happening around our organization in the changing world of healthcare.
Title: Reviewing Medical Director - Work at Home
Requisition ID: 188529
Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.