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The Lead Medical Director relies on medical background and reviews health claims. The Lead Medical Director requires a solid understanding of how organization capabilities interrelate across department(s).
The Lead Medical Director provides clinical and operational leadership for medical review activities supporting Home Health, Skilled Nursing Facility, Durable Medical Equipment, Medicare/Medicaid dual-eligible requests, and related home care solutions. Grounded in CMS Medicare guidance and applicable regulatory requirements, this role ensures consistent, timely, fair, compliant, and evidence-based medical necessity determinations for Medicare, Medicaid, and Dual Eligible populations.
Leadership and Team Operations
Oversee daily operations of a team of Medical Directors conducting appeals and clinical case reviews for Medicare and Dual Eligible populations.
Maintain Medical Director staffing schedules, including paid time off, weekend coverage, after-hours coverage, and call rotation planning.
Lead regular team meetings and cross-functional meetings with internal stakeholders, operational partners, and leadership.
Foster development of Medical Directors through coaching, collaboration, education, and non-case review activities.
Support team engagement and promote a collaborative culture aligned with organizational excellence and Humana's leadership expectations.
Partner with the Director of Physician Leadership and other Lead Medical Directors to ensure consistency in processes, expectations, and performance.
Clinical Case Review and Medical Necessity Determinations
Conduct clinical case reviews for approximately 50% of the role's responsibilities.
Review Medicare, Medicaid, and Dual Eligible member cases to determine medical necessity and appropriateness of requested services.
Evaluate requests related to home health, skilled nursing facility services, durable medical equipment, and other home-based care services.
Provide clinical interpretation and medical decisions regarding services requested or provided by other healthcare professionals.
Apply national clinical guidelines , CMS requirements, Humana policies, clinical standards, review procedures, and applicable contracts consistently.
Identify and resolve complex clinical, technical, and operational issues that arise during case review or appeals processes.
Regulatory Compliance and Medicare Requirements
Ensure timely completion of clinical reviews and appeals to meet Medicare regulatory requirements.
Support compliance with CMS Medicare guidance, Medicare Advantage requirements, Medicaid requirements, and applicable federal and state laws.
Promote consistency, accuracy, fairness, and timeliness in medical necessity determinations.
Support team performance related to CMS Star measures, particularly Timeliness and Fairness measures.
Ensure all clinical review work is conducted within Humana's and OneHome's regulatory compliance framework.
Cross-Functional Partnership and OneHome Support
Develop collaborative relationships with key partners across the Medicare Line of Business, Home Care Solutions , OneHome, internal operations teams, and leadership.
Serve as a clinical leader and subject matter resource for OneHome activities.
Help align medical review practices with OneHome's operational model andHumana's broader Medicare and home care strategy.
Support implementation of processes that improve service delivery, member experience, provider collaboration, and operational efficiency.
Participate in meetings with business, clinical, operational, and compliance partners to address performance, process, and clinical review needs.
Operational Improvement and Performance Management
Identify opportunities to improve medical management operations, workflow efficiency, review consistency, and case turnaround times.
Support process improvement efforts related to home health, skilled nursing facility, durable medical equipment, Medicare, Medicaid, and Dual Eligible requests.
Analyze clinical information and operational data to identify trends, risks, performance gaps, and opportunities for improvement.
Promote workflow efficiencies through effective use of technology, systems, and standardized review practices.
Contribute to scalable solutions that support OneHome and the evolving needs of Medicare members.
Education, Communication, and Clinical Expertise
Participate in required educational activities, clinical conferences, and internal learning forums.
Create and present educational content based on clinical subject matter expertise.
Communicate clearly and professionally with Medical Directors, operational partners, leadership, and other stakeholders.
Translate complex clinical guidelines, CMS policies, and Medicare requirements into clear guidance for consistent decision-making.
Support knowledge-sharing across the Medical Director team to strengthen clinical review quality and consistency .
Member and Consumer Experience
Deliver clinical decisions that support appropriate care, regulatory compliance, and a positive consumer experience
Promote fair, timely, and evidence-based decisions for Medicare, Medicaid, and Dual Eligible members
Help reduce unnecessary complexity in the clinical review process for members, providers, and internal partners
Support Humana's commitment to improving access, quality, and coordination of home-based care solutions
Alignment to Humana Leadership Expectations
Modeling customer-focused decision-making
Simplifying complex clinical and operational processes
Collaborating across teams and business functions
Supporting bold, outcome-oriented improvements
Anticipating operational needs associated with OneHome
Promoting shared accountability across clinical, operational, and compliance teams
At Humana, we are committed to helping people achieve their best health by delivering care and service with humanity, clarity, collaboration, and accountability. Through the Humana Way, we bring our values to life by working together to create simpler, better, and faster experiences for our members, patients, teammates, and business partners.
Use your skills to make an impact
Required Qualifications
Doctor of Medicine (MD/DO) degree from an accredited university in the USA
Current and ongoing board certification in an approved ABMS Medical Specialty
Active unrestricted license in at least one jurisdiction and willing to obtain additional licenses, as required, for various states in region of assignment
2+ years of leadership experience
5+ years of direct clinical patient care experience post-residency or fellowship
No current sanction from Federal or State Governmental organizations and the ability to satisfy onboarding requirements
There are holiday and weekend requirements for this role
Excellent verbal and written communication skills with analytic and interpretative skills from prior experience focusing on quality, utilization, and/or case management
Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual
Sponsorship is not available for this role
Preferred Qualifications
Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
Internal Medicine, Family Practice, Geriatrics, Hospitalist clinical specialists, inpatient and/or care of a Medicare type population (disabled or >65 years of age)
Previous Medicare, Medicaid, and/or Commercial experience
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