Medical Director-KY Medicaid
Company: Humana
Location: Rogers
Posted on: January 25, 2023
|
|
Job Description:
DescriptionThe Medical Director's primary responsibility is the
review of medical authorizations or claims to determine the medical
necessity of a given service or level of care. 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.ResponsibilitiesThe Medical Director actively uses their
medical background, experience, and judgement to make
determinations whether requested services, requested level of care,
and/or requested site of service should be authorized. All work
occurs within a context of regulatory compliance, and work is
assisted by diverse resources, which may include national clinical
guidelines, KDMS state policies, CMS policies and determinations,
clinical reference materials, internal teaching conferences, and
other reference sources. Medical Directors will learn KY Medicaid
requirements, and will understand how to operationalize this
knowledge in their daily work.The 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,
and possible participation in care management. The clinical
scenarios arise from outpatient, inpatient or post-acute care
environments. The Medical Director will have discussions with
external physicians by phone to gather additional clinical
information or discuss determinations through the Peer 2 Peer
process, and in some instances these may require conflict
resolution skills. Other duties include, but may not be limited to,
an overview of coding practices and clinical documentation,
grievance and appeals processes (including pharmacy), and reviews
for DME, genetic testing, etc. within their scope.The Medical
Director may occasionally speak with contracted external
physicians, physician groups, facilities, or community groups to
support regional market priorities, which may include an
understanding of Humana processes, as well as a focus on
collaborative business relationships, value based care, population
health, or disease or care management. Medical Directors support
Humana values, and Humana's Bold Goal mission, throughout all
activities.ResponsibilitiesThe Medical Director provides medical
interpretation and determinations whether services provided by
other healthcare professionals are in agreement with national
guidelines, KDMS and CMS requirements, Humana policies, clinical
standards, and contracts. The ideal candidate supports and
collaborates with other team members, other departments, Humana
colleagues and the Regional VP Health Services. After completion of
structured and mentored training, daily work is performed with
minimal direction, but with ready support from other team members.
Enjoys working in a structured environment with expectations for
consistency in thinking and authorship. Exercises independence in
meeting departmental expectations, and meets compliance timelines.
Supports the assigned work with respect to market-wide objectives
(e.g. Bold Goal) and community relations as directed.Candidates
must be willing and able to obtain a Kentucky license. Candidates
may live anywhere and must be willing to work Eastern Time Zone
hours.Required Qualifications
Keywords: Humana, Rogers , Medical Director-KY Medicaid, Executive , Rogers, Arkansas
Click
here to apply!
|