Regional Vice President overseeing account management and clinical guidance for national clients at Elevance Health. Collaborating with sales and account management teams to enhance healthcare quality and outcomes.
About the role
- Medical Director leading review of health claims and clinical evaluations at Humana. Utilizing medical expertise for regulatory compliance and operationalizing Medicare requirements with a team.
Responsibilities
- 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.
- 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.
- 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.
Requirements
- 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
- 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 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.
Benefits
- medical, dental and vision benefits
- 401(k) retirement savings plan
- time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
- short-term and long-term disability
- life insurance and many other opportunities
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