Medical Director - PI, Claims
Core
Medical Director reviews health claims and makes determinations on service authorization, level of care, and site of service for Medicare/Medicare Advantage populations.
Role type
Senior IC medical director (utilization management)
Builds
Clinical determinations and care management decisions for Humana members
Domain
Healthcare / Insurance / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
medical interpretation, clinical determinations, evidence-based criteria application, regulatory compliance, conflict resolution, independent judgment, clinical documentation review
Preferred skills
managed care industry knowledge, utilization management experience, national guidelines familiarity (MCG/InterQual), population health, analytics, case management
Technologies
CMS policies, MCG, InterQual
Responsibilities
Provide medical interpretation and clinical determinations regarding service alignment with guidelines and policies; Review clinical information and apply evidence-based criteria to support consistent, compliant medical decisions; Collaborate with cross-functional departments and stakeholders to support market-wide objectives; Perform daily work with minimal direction while maintaining alignment with departmental standards; Exercise independent judgment in meeting operational goals and compliance timelines; Communicate clinical determinations clearly to internal and external stakeholders
Seniority
Senior, hands-on IC