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.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.Conducts clinical reviews of the care received by members in assigned LTSS Medicaid states, member population, or condition type.Communicates decisions to internal associates, participates in Grievance & Appeal reviews, and attends Fair Hearings.May need to have discussions with external physicians, providers, Care Coaches, and UM Team associates to gather additional clinical information or discuss determinations.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 experience.Must have a current License in Florida and able to obtain License / s in Indiana, Virginia, Georgia, and / or other LTSS Medicaid states as needed.MD or DO degree.Board Certified in an approved ABMS Medical Specialty.Excellent communication skills with 5 years of established clinical experience.Knowledge of the managed care industry including Medicare or Medicaid products.Possess analysis and interpretation skills with 5 years of experience focusing on quality management, utilization management, discharge planning, rehabilitation services, and / or home health services.Preferred QualificationsExperience with LTSS medical management organizations, Skilled Nursing Facilities, Long Term Care Facilities, Hospice, PACE, or Home Health Agencies.Internal Medicine, Physiatry, Family Practice, Geriatrics, Pediatrics, or Hospitalist experience.Previous Medicare, Medicaid, and / or Commercial experience with 5 years of experience.Long Term Services & Supports or LTC / SNF with 5 years of experience preferred.Scheduled Weekly Hours40Pay RangeThe compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$223,800 - $313,100 per yearThis job is eligible for a bonus incentive plan based on 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 while also knowing your life extends outside of work.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