Medical Director - Claims
Core
Authorize requested services, determine level of care, and select site of service for Medicare/Medicaid members via computer-based review of complex clinical scenarios.
Role type
Senior Utilization Management Medical Director
Builds
Clinical determinations and appeals decisions for Humana's Medicare Advantage and Managed Medicaid populations
Domain
US Healthcare / Managed Care / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical judgment, regulatory compliance analysis, conflict resolution, care management, coding practices, national guideline interpretation (MCG/InterQual), team collaboration
Preferred skills
MBA/MHA/MPH, population health analytics, social determinants of health familiarity, case management experience
Technologies
MCG, InterQual, CMS policy databases, clinical reference materials
Responsibilities
Review clinical records for inpatient/outpatient/post-acute scenarios, communicate determinations to internal associates, discuss cases with external physicians, participate in grievance/appeals processes, support regional market priorities
Seniority
Senior, hands-on IC with mentorship potential