Medical Director (OP/DME/Pharmacy)
Humana 1,141 reviews - Louisville, KY

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You will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS, DOI, Humana and other nationally recognized and accepted guidelines.
  • Provide physician review services for utilization management, case management, quality management for Out-Patient, DME, and Pharmacy.
  • Develop, maintain and assure compliance with physician review policies and procedures (including timeliness) for utilization management and support case management.
  • Support collaborative relationships with physicians, large provider groups, hospitals, other facilities and ancillary providers.
  • Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols.
  • Examine clinical programs information to identify members for specific case management and/or disease management activities or interventions by utilizing established screening criteria.
  • Conduct admission review, post-discharge and discharge planning with clinical staff and peers
  • Onsite rounding with clinical staff to support utilization and case management
Key Competencies
                      • 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.

                      Role Essentials
                      • A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment
                      • MD or DO degree
                      • Board Certified in a ABMS Medical Specialty
                      • Five years clinical experience.
                      • Excellent communication skills
                      Role Desirables
                      • Health Plan experience
                      • Previous Medicare/Medicaid Experience
                      • Previous experience leading teams focusing on utilization management, discharge planning and/or home health or rehab
                      • 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.
                      Schedule : Full-time

                      Primary Location : US-KY-Louisville

                      Role : Clinical Innovations and Health Practitioners

                      Work Environment Type : Virtual/Work At Home

                      Travel : Yes, 10 % of the Time

                      About this company
                      1,141 reviews
                      Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...