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
- 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 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
- 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.
Clinical Innovations and Health Practitioners
Work Environment Type
Virtual/Work At Home
Yes, 10 % of the Time
Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...