Experience Inc. Jobs

Become a part of our caring community and help us put health first

The Medical Director’s primary responsibility is the review of medical authorizations to determine the medical necessity of a given service, level of care, or medical item/supply. The Medical Director’s work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors that rely on clinical experience and knowledge of both medicine and social determinants of health. Candidates must have current/active Florida license and be willing to work East Coast hours. Please see position requirements for licensing details.

Candidates must have current/active Florida medical license and be willing to work East Coast hours. Please see position requirements for licensing details.

The LTSS Reviewing Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, requested site of service, and/or medical supply should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Director will learn National LTSS State Medicaid requirements (currently FL; IN; and other states as needed) and understand how to operationalize this knowledge into their daily work.

The LTSS Reviewing Medical Director’s work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, Grievance & Appeal reviews, participation in ICT’s (Intra Collaborative Team meetings); and attend Fair Hearings. The clinical scenarios arise from outpatient, post-acute care; acute inpatient; LTC (Long Term Care); and HCBS (home and community based services) environments. Reviews include, but not limited to, home health services, therapy services, consumable medical supplies (CMS); home or vehicle modifications, and durable medical equipment (DME).

Other duties include, but may not be limited to, an overview of clinical documentation, Letter of Agreements, coding practices, Clinical Integration, Long Term Services & Supports, and Case Management. The Medical Director, as indicated, could need to have discussions with external physicians, providers, Care Coaches, and UM Team associates by phone or internal messaging to gather additional clinical information or discuss determinations, and in some instances these discussions may require conflict resolution skills.

The LTSS Reviewing Medical Director may occasionally speak with contracted external physicians, provider groups, health care facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value based care, population health, or disease or care management.

Use your skills to make an impact

Responsibilities

The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines.

Required Qualifications

• 5+ years of clinical experience

• Must have a current License in Florida and able to obtain License/s in Indiana, Virginia, Georgia, and/or other LTSS Medicaid states as needed

• MD or DO degree

• Board Certified in an approved ABMS Medical Specialty

• Excellent communication skills with 5+ years of established clinical experience

• Knowledge of the managed care industry including Medicare or Medicaid products

• Possess analysis and interpretation skills with 5+ years of experience focusing on quality management, utilization management, discharge planning, rehabilitation services, and/or home health services

Preferred Qualifications

• LTSS medical management organizations, Skilled Nursing Facilities, Long Term Care Facilities, Hospice, PACE, or Home Health Agencies and experience, working with health insurance other healthcare providers, patient interaction, etc.

• Internal Medicine, Physiatry, Family Practice, Geriatrics, Pediatrics, or Hospitalist experience

• Previous Medicare, Medicaid, and/or Commercial with 5+ years of experience

• Long Term Services & Supports or LTC/SNF with 5+ years of experience preferred

• Call on average is 10 weekends per year.

Additional Information

• The Medical Director conducts clinical reviews of the care received by members in assigned LTSS Medicaid states, member population, or condition type. Must hold a MD or DO and be board certified and typically reports to a Lead or Regional or Corporate Medical Director, depending on size of region/line of business. No direct supervisory responsibility is expected though it may occur.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$223,800 - $313,100 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 03-30-2025

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.