Medical Director - Meridian, United States - Idaho State Job Bank

Idaho State Job Bank Meridian, United States

3 weeks ago

Description

Medical Director

Midwest Region at Humana in Meridian, Idaho, United States Job Description Description 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 within 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 reference sources.

Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.

Responsibilities 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. 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 activities.

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 structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members.

Enjoys working in a structured environment with expectat To view full details and how to apply, please login or create a Job Seeker account

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