Responsibilities:

• Use clinical training, professional experience, and sound medical judgment to determine whether requested services, level of care, or site of service should be authorized.

• Make determinations in accordance with regulatory and compliance requirements and with support from approved resources, including national clinical guidelines, state Medicaid policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other established sources.

• Develop and maintain a working knowledge of Medicaid requirements and apply that knowledge effectively in daily work within the assigned cluster.

• Perform computer-based reviews of moderately complex to highly complex clinical cases from both outpatient and inpatient settings.

• Review all submitted clinical documentation and supporting records to determine medical necessity and appropriateness of care.

• Prioritize daily review work to meet operational expectations and turnaround requirements.

• Communicate determinations and rationale to internal associates in a timely and professional manner.

• Participate in care management-related activities, as appropriate.

• Conduct peer-to-peer discussions with external physicians by phone to obtain additional clinical information and discuss medical necessity determinations.

• Use effective communication and conflict resolution skills in peer-to-peer conversations, particularly in cases involving disagreement or escalated review.

• Collaborate with contracted physicians, physician groups, facilities, and community organizations in support of regional market priorities.

• Demonstrate knowledge of Humana processes while fostering collaborative relationships that support value-based care, population health, and disease or care management initiatives.

• Support Humana’s values and the mission of the Enterprise Social Needs team in all activities and interactions.

• Provide cross-coverage and flow to work across the assigned cluster, as needed, for vacations, weekends, and holiday coverage.

Qualifications:

• Doctor of Medicine or Doctor of Osteopathy

• Board-certified in ABMS recognized specialty

• A current and unrestricted license in at least one of the states that are part of the specific cluster: IN, OH, KY, VA, WI, & IL and ability to obtain unrestricted licenses in the other cluster states that require licensure.

• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting

• Experience with accreditation process (NCQA)

• Experience with CGX and MHK

• Experience in utilization management review and case management in a health plan setting

Reporting Relationship:

This position reports directly to the Cluster Lead Medical Director.

Location:

This role is based virtually in one of the states of the specific cluster, which includes: IN, OH, KY, VA, WI, & IL

Work Style: Fully Remote; may be required for occasional travel to onsite Humana Hubs

Work Hours:

Typical business hours are Monday-Friday, 8 hours/day, 5 days/week some flexibility might be possible, depending on business needs.

Interview Format

As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers with an enhanced method for decision-making through on-demand candidate assessments.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions. You should anticipate the assessment to take approximately 10-15 minutes.

Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

SSN Task via Workday

Should you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.

Scheduled Weekly Hours

Pay Range

Description of Benefits