LasVegasRecruiter Since 2001
the smart solution for Las Vegas jobs

Reviewing Medical Director

Company: Humana
Location: Las Vegas
Posted on: September 17, 2020

Job Description:

Description

Description 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. Responsibilities Job Title: Medical Director Location: Work At Home Schedule: Variable and dependent on market needs 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. 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 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 expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines. Supports the assigned work with respect to market-wide objectives (e.g. Bold Goal) and community relations as directed. 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). + Board Certified in an approved ABMS Medical Specialty with continued certification throughout employment. + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills. + Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on 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 specialization + Advanced degree such as an MBA, MHA, or MPH + Exposure to Public Health principles, 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 Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. Some medical directors may join a centralized team for several months after training, until positions become available for specific markets. May participate on project teams or organizational committees. #physiciancareers Scheduled Weekly Hours 40 About Us Mission: At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms -when and where they need it. Our employees are at the heart of making this happen and that's why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first. Equal Opportunity Employer It is our policy to recruit, hire, train, and promote people without regard to race, color, religion, sex, national origin, age, sexual orientation, gender identity or expression, disability, or veteran status, except where age, sex, or physical status is a bona fide occupational qualification. View the EEO is the Law poster. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this online application process and need an alternative method for applying, you may contact mailbox_tas_recruit@ for assistance. Humana Safety and Security Humana will never ask, nor require a candidate provide money for work equipment and network access during the application process. If you become aware of any instances where you as a candidate are asked to provide information and do not believe it is a legitimate request from Humana or affiliate, please contact mailbox_tas_recruit@ to validate the request. California Residents If you are a California resident and would like to review our California Consumer Privacy Act (CCPA) Policy click here: CA Resident Privacy Policy

Associated topics: analyst, government, major gift, marketing, medical center, policy, public relations, regulatory, social media, solicitation

Job Information

Job ID: ba5122c0-12614530911

Keywords: Humana, Las Vegas , Reviewing Medical Director, Other , Las Vegas, Nevada

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Other Jobs


91B Light-Wheel Vehicle Mechanic
Description: Job Description As a Light-Wheel Vehicle Mechanic for the Army National Guard you ll ensure that anything that moves on wheels is ready to hit the road. In this role, you will primarily be responsible (more...)
Company: National Guard
Location: Las Vegas
Posted on: 09/26/2020

Outside Sales – Interviewing Experienced and Entry Level
Description: If you re exploring sales careers, you already know sales is the way to get ahead. You can sell just about anywhere, but the key is knowing how to spot the right opportunity. Have you ever noticed (more...)
Company: Platinum
Location: Indian Springs
Posted on: 09/26/2020

Food Courier
Description: Your time. Your Goals. What is DoorDash Available in over 4,000 cities in the U.S., Canada, and Australia, DoorDash is about connecting people with possibilities: bigger savings accounts, wider nets, (more...)
Company: Doordash
Location: Las Vegas
Posted on: 09/26/2020


Emergency Medical Technician (EMT) (Part Time)
Description: Emergency Medical Technician EMT Part Time 1,719 locations Part-time Salary: 13.00 to 33.00 /hour Be part of a team. The Army provides an opportunity for you to secure your future, advance (more...)
Company: U.S. Army
Location: Las Vegas
Posted on: 09/26/2020

Emergency Medical Technician (EMT) (Full Time)
Description: Emergency Medical Technician EMT Full Time 1,719 locations Full-time Salary: 20,000.00 to 70,000.00 /year Be part of a team. The Army provides an opportunity for you to secure your future, (more...)
Company: U.S. Army
Location: Las Vegas
Posted on: 09/26/2020

Delivery Driver / Courier
Description: No passengers. No bosses. Just you, your tunes, and the road. Sign up now and start making money Choose your wheels and deliver food and other items from local merchants to
Company: Doordash
Location: Las Vegas
Posted on: 09/26/2020

Human Resources Assistant (Army) Part-Time
Description: Human Resources Assistant Army Part-Time READ FIRST This position requires joining the Army and completing these duties as a soldier As a part of a team of soldiers, you secure (more...)
Company: U.S. Army
Location: Las Vegas
Posted on: 09/26/2020

Food Courier
Description: Your time. Your Goals.What is DoorDashAvailable in over 4,000 cities in the U.S., Canada, and Australia, DoorDash is about connecting people with possibilities: bigger savings accounts, wider nets, stronger (more...)
Company: Doordash
Location: Las Vegas
Posted on: 09/26/2020

Truck Driver (Army) (Part-Time)
Description: Truck Driver Army Part-Time As a part of a team of soldiers, you secure your future with a career in the Active Duty Army Part time , pay for college, guaranteed healthcare with family benefits. (more...)
Company: U.S. Army
Location: Las Vegas
Posted on: 09/26/2020

Sales – Training Offered
Description: If you re exploring sales careers, you already know sales is the way to get ahead. You can sell just about anywhere, but the key is knowing how to spot the right opportunity. Have you ever noticed (more...)
Company: Platinum
Location: Indian Springs
Posted on: 09/26/2020

Log In or Create An Account

Get the latest Nevada jobs by following @recnetNV on Twitter!

Las Vegas RSS job feeds