You will collaborate with other health care givers in reviewing actual and proposed medical care and services against established DOI guidelines.
- Provides support and guidance for appeals, medication prior-authorization requests, and benefit designs and levels
- Develop, maintain and assure compliance with physician review policies and procedures (including timeliness) for utilization management and support case management
- Conduct admission review, post-discharge and discharge planning with clinical staff and peers
- Onsite rounding with clinical staff to support utilization and case management
- Leveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
- Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.
- Is Accountable: You meet clearly stated expectations and take responsibility for achieving results.
- Clinical Knowledge: You understand clinical program design, implementation, management/monitoring to support choice in consumer medical care. Understands the medical utilization implications of such programs
- Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.
- A current and unrestricted license in KY, and willing to obtain license, as required, for various states in region of assignment
- MD or DO degree
- Board Certified in an approved ABMS Medical Specialty
- 5+ years clinical practice experience with strong knowledge of the managed care industry
- Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
- Process-oriented, evidence-based and scientifically-inclined, consistent, enjoys being a part of a team, thoughtful and has a thirst for continuous education and development.
- Excellent telephonic communication skills; excellent interpersonal communication skills
- Experience in community based and chronic disease management
- Board Certification in Internal Medicine or Family Medicine
- Proficiency in working in a matrix environment
- Previous experience leading teams focusing on utilization management, discharge planning and/or home health or rehab
Clinical Innovations and Health Practitioners
Work Environment Type
Virtual/Work At Home
Yes, 5 % of the Time
Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...