Humana Reviewing Medical Director - Medicare Advantage, TX in Corpus Christi, Texas
Role Assignment: Reviewing Medical Director – Medicare Advantage Location: *Austin,*San Antonio/Corpus Christie, TX OR WAH
Are you a fit? Do you enjoy defining clinical strategy and clinical outcomes for a major market area? Do you have a desire to be in a position where you can provide guidance to our members related to their health care needs? Does this sound like you? If so, then read on!
For the region of Greater Fort Worth, Geater Dallas and North Texas the incumbent 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, and conduct peer to peer reviews
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.
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 an approved ABMS Medical Specialty
Five years clinical experience
Excellent communication skills
Technical ability with Microsoft Applications and other computer based programs Role Desirables
A minimum of 5 years patience facing experience – post residency.
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
Title: Reviewing Medical Director - Medicare Advantage, TX
Other Locations: US-Texas-Corpus Christi, US-Texas-San Antonio, US-Texas
Requisition ID: 187274
Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.