Medical Director - OneHome
Core
Review clinical cases to determine medical necessity for Medicare and Medicaid members, ensuring compliance with CMS guidelines and organizational policies.
Role type
Senior Medical Director (Regulatory & Clinical Review)
Builds
Compliance decisions and medical management operational improvements for Humana's Home Health, SNF, and DME services.
Domain
US Healthcare (Medicare/Medicaid)
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical case review, CMS/Medicare/Medicaid policy interpretation, regulatory compliance, operational improvement identification, call rotation management, educational content creation
Preferred skills
Inpatient/outpatient experience, care of Medicare population (disabled or >65), Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, Surgery
Technologies
Microsoft Office, Internet navigation
Responsibilities
Review clinical cases and determine medical necessity; Ensure compliance with review policies and regulatory standards; Apply clinical guidelines and CMS policies; Identify opportunities for medical management operational improvements; Participate in call rotations including weekend and after-hours coverage; Contribute to team culture and deliver consumer experiences; Participate in educational activities and conferences
Seniority
Senior, hands-on IC with leadership reporting