Physical Health Medical Director

About the role

The Medical Director is responsible for Medicaid care strategy and/or operations. Work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

• Uses medical background, experience, and judgement to make determinations whether requested services, level of care, or site of service should be authorized, within a context of regulatory compliance and assisted by diverse resources (e.g., national clinical guidelines, state policies, CMS policies, clinical reference materials, internal teaching conferences).
• Learns Medicaid requirements and understands how to operationalize this knowledge in daily work within the assigned cluster.
• Includes computer-based review of moderately complex to complex clinical scenarios, review of submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management.
• Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process, which may require conflict resolution skills.
• May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, focusing on collaborative business relationships, value-based care, population health, or disease/care management.
• Supports Humana values and the enterprise social needs team mission throughout all activities.
• Provides coverage within the cluster as needed for vacations, weekends, and holidays.

Qualifications

• Doctor of Medicine or Doctor of Osteopathy.
• Board-certified in an ABMS or ABPN recognized specialty.
• A current and unrestricted medical license in at least one of the states within the assigned cluster (IN, OH, KY, VA, WI, IL), with the ability to obtain licenses in other cluster states requiring licensure.
• Able to satisfy onboarding requirements.
• At least five years of experience post-training providing clinical services.
• Experience in utilization management review and case management in a health plan setting.
• No current sanctions from Federal or State Governmental organizations and able to pass credentialing requirements.
• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting.
• Experience with accreditation processes (e.g., NCQA).
• Experience with CGX and MHK.
• Licensure through the Interstate Medical Licensure Compact (preferred).

Work Arrangement

• This is a virtual role based in one of the following states: IN, OH, KY, VA, WI, or IL.
• Work at home requirements:
  • Self-provided internet service with a minimum download speed of 25 Mbps and upload speed of 10 Mbps (wired cable or DSL connection suggested).
  • Work from a dedicated space free of ongoing interruptions to protect member PHI/HIPAA information.
• Occasional travel to Humana's offices for training or meetings may be required.
• Scheduled weekly hours: 40.

Pay

The starting base pay range for this full-time position is $223,800 - $313,100 per year. Pay may vary based on geographic location and individual qualifications, including skills, knowledge, experience, education, and certifications. This role is also eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, including company and personal holidays, paid parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance.
• Additional opportunities supporting whole-person well-being.

Reporting Relationship

This position reports directly to the Cluster Lead Medical Director.