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Medical Director

N/A, NY, USA | Humana

  • Industry:
    Insurance - Health & Life
  • Position Type:
  • Functions:
    General Management
  • Experience:
    5-7 years
Job Description:
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Imagine using your workday to make a meaningful difference in people's lives. 

Envision working in an environment where you are not only encouraged to create a positive change but also given the tools to make that change happen. 

Welcome to Humana Edge—we are the future of healthcare! 

Our mission is to transform the experience that we provide for seniors working to meet their social, emotional, and medical needs. As an Edge associate, you will guide members through their healthcare journey, ensuring they get the guidance and support they need so they can focus on fulfilling their life's ambitions and goals. At the Edge, whole person health is about discovery, connections and community. This is a unique opportunity to help shape the technology-enabled services we will build together to deliver on our shared vision. We are looking for individuals who are:

• Passionate about transforming our care system for those who need it most

• Driven to do well by doing what's right as guided by those we serve

• Willing to thoughtfully disrupt the status quo and excited to work in a rapidly evolving start-up environment.

Be a part of Humana Edge, focused on providing a seamless healthcare experience of the highest quality to Medicare Advantage members using traditional and virtual modalities to meet members where they’re most comfortable.


The primary focus of the Medical Director is to work assignments that involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors with medical claims.

Primary Responsibilities

The Medical Director will:

Complete digital review of moderately complex to complex clinical scenarios that arise from inpatient or post-acute care environments which includes review of all submitted clinical records and prioritization of daily work

Make determinations whether requested services, requested level of care, and/or requested site of service should be authorized (in accordance with regulatory compliance which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise 

Provide 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  

Collaborate 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

Communication of decisions to internal associates, and possible participation in care management

Support and collaborate with other team members, other departments, Humana colleagues  

Enjoy working in a structured environment with expectations for consistency in thinking and authorship

Exercise independence in meeting departmental expectations, and meets compliance timelines

Support the assigned work with respect to market-wide objectives (e.g. Bold Goal) and community relations as directed

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

Support Humana values, and Humana’s Bold Goal mission, throughout all activities 

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) or outpatient, labs, and DME in place of inpatient and post-acute

Current and ongoing Board Certificationan approved ABMS Medical Specialty

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 passcredentialing 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 specialists

Advanced degree such as an MBA, MHA, MPH

Exposure to 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

Typically reports to 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. May participate on project teams or organizational committees.

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