Medical Director - PI, Claims

Become a part of our caring community   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, and possible participation in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. 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.  Some roles include 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 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. Medical Directors support Humana values, and Humana’s Bold Goal mission, throughout all activites. Use your skills to make an impact   Responsibilities Provide medical interpretation and clinical determinations regarding whether services provided by healthcare professionals align with applicable national guidelines, CMS requirements, Humana policies, clinical standards, and relevant contract requirements. Review clinical information and apply evidence-based criteria to support consistent, compliant, and well-documented medical decisions. Collaborate with team members, cross-functional departments, Humana colleagues, and the Regional VP of Health Services to support departmental and market-wide objectives. Perform daily work with minimal direction after completion of mentored training, while maintaining alignment with departmental standards and expectations. Work effectively in a structured environment that requires consistency in clinical reasoning, decision-making, documentation, and authorship. Exercise independent judgment in meeting departmental expectations, operational goals, and compliance timelines. Support market-wide health objectives, including initiatives such as Bold Goal, and contribute to community relations activities as directed. Partner with internal stakeholders to promote quality outcomes, appropriate utilization, and adherence to clinical and regulatory requirements. Maintain current knowledge of applicable clinical standards, regulatory guidance, CMS requirements, and organizational policies relevant to medical decision-making. Communicate clinical determinations clearly and professionally to appropriate internal and external stakeholders. Contribute to process consistency, quality improvement, and operational effectiveness within the assigned area of responsibility. Demonstrate professionalism, accountability, and collaboration in support of Humana’s clinical, compliance, and business objectives. At Humana, we