The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing Home Health, SNF, DME, dual Medicare/Medicaid requests. The Medical Director reviews and determines whether healthcare services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and applicable contracts.
The Medical Director evaluates the medical necessity of healthcare services, ensuring decisions comply with regulatory and organizational standards. The role requires interpreting clinical guidelines, CMS policies, and Medicare requirements, and applying them consistently. All work at OneHome is conducted within a framework of regulatory compliance. This secures compliance with all requirements set by federal and state laws. Medical Directors review clinical cases for Medicare and Medicaid members, report to the Lead Medical Director, and work within defined timelines and departmental expectations.
Role Responsibilities:
- Review clinical cases and determine medical necessity of services for Medicare and Medicaid members.
- Ensure compliance with review policies, procedures, and regulatory standards.
- Apply clinical guidelines, CMS policies, and Medicare/Medicare Advantage/Medicaid requirements.
- Identify opportunities for medical management operational improvements.
- Participate in call rotations, including weekend coverage and after-hours coverage.
- Contribute to an engaged, collaborative team culture that supports organizational excellence.
- Deliver exceptional consumer experiences.
- Participate in educational activities by attending required conferences and creating content to present for individual subject matter contribution.
- Support Home Solutions and other activities as assigned by the OneHome leadership.
Use your skills to make an impact
Required Qualifications
- MD or DO degree
- Current, active and ongoing board certification from the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialties (AOABPS). National Board of Physicians & Surgeons (NBPAS) certification is not accepted.
- Current and unrestricted state license in at least one state and willing to obtain other medical licenses, as required, for various states in region of assignment.
- No sanctions from Federal or State Governmental organizations
- 5 years of direct clinical patient care experience post residency or fellowship.
- The ability to pass credentialing requirements.
- Intermediate to advanced skills utilizing Microsoft Office and Internet navigation.
- Strong verbal and written communication skills, with the ability to analyze information and interpret data clearly and accurately.
- Adaptable and willing to learn new technologies to enhance workflow efficiency.
Preferred Qualifications
- Experience in an inpatient and/or outpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age).
- Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, Surgery or hospital based clinical specialists.
Additional Information
- Workstyle: Remote work at home
- Hours: Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, call rotations, including weekend coverage and after-hours coverage. Must be able to work in local/residing time zone post-training.
- Training: 5 weeks of onboarding, no time off and training is in Eastern Standard Time (EST).
Work at Home Requirements
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The 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 year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, 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. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
