Humana Inc., headquartered in Louisville, Kentucky, is one of the nation´s largest publicly traded health benefits companies.
Humana offers a diversified portfolio of health insurance products and related services - through traditional and consumer-choice plans - to employer groups, government-sponsored plans, and individuals. Today, Humana is a leader in consumer engagement. Throughout its diversified customer portfolio, the company provides guidance that can both help lower costs and lead to a better health plan experience.Role: Associate Medical Director, Southeast RegionAssignment: Senior ProductsLocation: Charlotte, NCAre you a fit?Do you enjoy defining clinical strategy for a major market area? Do you have a desire to be in a position where you can provide guidance to our members related to their health care needs?Assignment CapsuleThe primary function for this individual will be to perform medical director internal reviews and external peer to peer reviews on Medicare Advantage cases (HMO, PPO and PFFS) and claims from our Southeast Region which includes Georgia, South Carolina and North Carolina.The position will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS and other peer review guidelines.Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using your knowledge of benefit plan design.Recommend services for Humana Medicare Advantage Plan members utilizing care alternatives available within the community and nationally. Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols.Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions by utilizing established screening criteria. Conduct admission review, peer to peer review and participate with Medicare Advantage nurses on discharge planning. Key CompetenciesLeveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.Is Accountable: You meet clearly stated expectations and take responsibility for achieving results.Clinical Knowledge: You understand clinical program design, implementation, management/monitoring to support choice in consumer medical care. Understands the medical utilization implications of such programsCommunication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience. Role Essentials- Current medical license in North Carolina- Minimum of 3 to 5 years of prior full or part-time experience doing medical director reviews either in a hospital setting, for a managed care company or for a quality assurance organization- Ability to work part-time 20-hours per week (or 4-hours per day, M-F) and become full-time within the next 12 months- Ability to be licensed in multiple states without restrictionsRole Desirables- Specialty in Internal Medicine or Family Practice with a sub-specialty in Geriatrics, Cardiology or Physical Medicine-Rehabilitation- Previous Medicare/Medicaid Experience - Previous experience leading teams focusing on utilization management, discharge planning and/or home health or rehab- Bilingual is a plus Reporting Relationships- You will report to the Regional Medical Director in Atlanta, GA.