Medical Director - Inpatient Review
Core
Review inpatient medical records to assess medical necessity based on national guidelines, CMS regulations, and Humana policies.
Role type
Senior IC physician utilization management specialist
Builds
Utilization management determinations for inpatient care
Domain
Healthcare insurance / Utilization review
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical case analysis, structured decision-making, regulatory compliance, clinical documentation, verbal communication, written communication
Preferred skills
Hospital medicine background, critical care experience, utilization management experience, familiarity with MCG or InterQual guidelines, Medicare population experience, clinical technology proficiency
Technologies
MCG, InterQual
Responsibilities
Conduct inpatient medical necessity reviews, analyze complex hospital-based cases, communicate review outcomes with external providers, collaborate within a multidisciplinary team
Seniority
Senior, hands-on IC