PCO Medical Director - UM - Part Time (Hourly)
Humana
Become a part of our caring community and help us put health first
The Medical Director, Primary Care relies on medical background and reviews health claims. The Medical Director, Primary Care work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.The Medical Director relies on medical background and reviews health claims. 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.
The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs with 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 sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily 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, participation in care management and possible participation in care facilitation with hospitals. The clinical scenarios predominantly arise from inpatient or post-acute care environments. There are 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. An aspect of the role includes an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market care facilitation and 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.
Use your skills to make an impact
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. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines.
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).
Current and ongoing Board Certification in an approved ABMS Medical Specialty as well as ABQAURP, or other board demonstrating advanced training in transitions of care, quality assurance, utilization management and care coordination.
A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required.
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
Excellent organizational, verbal and written communication skills.
Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on transitions of care, quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation.
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.
Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance.
Experience with national guidelines such as MCG® or InterQual.
Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists
Advanced degree such as an MBA, MHA, MPH
Exposure to value-based care, Public Health, Population Health, analytics, and use of business metrics.
Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.
The curiosity to learn, the flexibility to adapt and the courage to innovate.
Additional Information
Will report to the Director of Physician Strategy at Utilization Management. The Medical Director conducts Utilization review of the care received by members in an assigned region, market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees.
Scheduled Weekly Hours
1Pay 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. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers benefits for limited term, variable schedule and per diem associates which are designed to support whole-person well-being. Among these benefits, Humana provides paid time off, 401(k) retirement savings plan, employee assistance program, business travel and accident.Application Deadline: 12-31-2025
About us
About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva’s innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being.About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.