Medical Director- South Central

Humana - Boise, ID

Full-time - Senior

Boise, ID

Insurance Carriers and Related Activities

About the position

The Medical Director at Humana plays a crucial role in ensuring that healthcare services are authorized based on medical necessity and compliance with regulatory standards. This position involves reviewing clinical scenarios, communicating decisions, and collaborating with healthcare professionals to support Humana's mission of putting health first. The Medical Director will utilize their medical expertise to interpret clinical information and guide care management processes, all while adhering to national guidelines and Humana policies.

Responsibilities

• Provide medical interpretation and determinations on service agreements with national guidelines and CMS requirements.
• Review moderately complex to complex clinical scenarios and submitted clinical records.
• Prioritize daily work and communicate decisions to internal associates.
• Engage in discussions with external physicians to gather clinical information or resolve conflicts.
• Support regional market priorities through collaboration with external physicians and community groups.
• Participate in care management and understand coding practices and clinical documentation.

Requirements

• Medical degree (MD or DO) with relevant clinical experience.
• Strong understanding of Medicare and Medicare Advantage requirements.
• Experience in clinical review and decision-making processes.
• Excellent communication skills for interaction with healthcare professionals.

Nice-to-haves

• Familiarity with Humana processes and policies.
• Experience in value-based care and population health management.
• Knowledge of grievance and appeals processes.

Benefits

• Comprehensive health insurance coverage.
• 401k retirement savings plan with matching contributions.
• Paid time off and holidays.
• Opportunities for continued education and professional development.