Physician Medical Director - LTSS

Become a part of our caring community and help us put health firstThe Long-term services and supports (LTSS) Medical Director’s primary responsibility is the review of medical authorizations to determine the medical necessity of a given service, level of care, or medical item / supply. The Medical Director’s work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors that rely on clinical experience and knowledge of both medicine and social determinants of health. Candidates must have current / active Florida license and be willing to work East Coast hours. Please see position requirements for licensing details.ResponsibilitiesThe Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts.The LTSS Reviewing Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, requested site of service, and / or medical supply should be authorized.The LTSS Reviewing 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, Grievance & Appeal reviews, participation in ICT’s (Intra Collaborative Team meetings); and attend Fair Hearings.Other duties include, but may not be limited to, an overview of clinical documentation, Letter of Agreements, coding practices, Clinical Integration, Long Term Services & Supports, and Case Management.The LTSS Reviewing Medical Director may occasionally speak with contracted external physicians, provider groups, health care facilities, or community groups to support regional market priorities.Required Qualifications5 years of clinical experienceMust have a current License in Florida and able to obtain License / s in Indiana, Virginia, Georgia, and / or other LTSS Medicaid states as neededMD or DO degreeBoard Certified in an approved ABMS Medical SpecialtyExcellent communication skills with 5 years of established clinical experienceKnowledge of the managed care industry including Medicare or Medicaid productsPossess analysis and interpretation skills with 5 years of experience focusing on quality management, utilization management, discharge planning, rehabilitation services, and / or home health servicesPreferred QualificationsLTSS medical management organizations, Skilled Nursing Facilities, Long Term Care Facilities, Hospice, PACE, or Home Health Agencies and experience, working with health insurance other healthcare providers, patient interaction, etc.Internal Medicine, Physiatry, Family Practice, Geriatrics, Pediatrics, or Hospitalist experiencePrevious Medicare, Medicaid, and / or Commercial with 5 years of experienceLong Term Services & Supports or LTC / SNF with 5 years of experience preferredScheduled Weekly Hours40Pay Range$223,800 - $313,100 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and / or individual performance.Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family.Equal Opportunity EmployerIt is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status.#J-18808-Ljbffr

Salary : $223,800 - $313,100