Medical Director - Acute Rehab

📋 Description

• • As a Medical Director for Acute Rehabilitation at Humana Inc., you will play a pivotal role in ensuring our members receive appropriate and high-quality care within the post-acute rehabilitation setting.
• • Your core responsibility will involve leveraging your extensive medical expertise, clinical judgment, and understanding of regulatory frameworks to meticulously evaluate authorization requests for acute inpatient rehabilitation services.
• • This includes determining the medical necessity, appropriateness of the requested level of care, and suitability of the proposed site of service, all while adhering to national clinical guidelines, Centers for Medicare & Medicaid Services (CMS) policies, and internal Humana standards.
• • You will become an expert in Medicare and Medicare Advantage requirements, with a specific focus on Special Needs Plans (DSNP), and will be instrumental in operationalizing this knowledge into your daily decision-making processes.
• • The role demands a rigorous approach to reviewing moderately complex to complex clinical scenarios, thoroughly examining all submitted clinical records, and effectively prioritizing your daily workload.
• • A key aspect of this position involves clear and concise communication of your determinations to internal Humana associates, ensuring seamless collaboration and understanding across teams.
• • You will engage in direct communication with external physicians via telephone to gather essential additional clinical information or to discuss and explain your medical determinations, which may occasionally require adept conflict resolution skills.
• • This position offers a unique opportunity to work within a structured environment that values consistency in clinical interpretation and documentation, while also fostering independence in meeting enterprise expectations and compliance timelines.
• • You will collaborate closely with other team members, various departments within Humana, and clinical leadership, contributing to a cohesive and effective healthcare delivery system.
• • After completing a comprehensive, structured, and mentored training program, you will be empowered to perform your daily duties with confidence and autonomy.
• • This is a full-time, fully remote opportunity, allowing you to work from anywhere in the United States, contributing 40 hours per week to our mission.
• • Your work will directly impact the health and well-being of our members by ensuring they receive the right care, at the right time, and in the right setting, particularly during critical recovery phases.
• • You will be involved in utilization management, contributing to the efficient and effective allocation of healthcare resources.
• • The role may also involve participation in grievance and appeals reviews, providing a critical medical perspective on member concerns.
• • Depending on the needs of the business, you may also contribute to project teams or organizational committees, further enhancing your impact and professional development.
• • You will be expected to maintain a high level of analytical and interpretive skills, applying them to quality management, utilization management, and acute inpatient rehabilitation initiatives.
• • A strong understanding of the managed care industry, including Medicare Advantage, Managed Medicaid, and other healthcare provider landscapes, is essential for success.
• • This role is ideal for a physician who thrives in a remote setting, possesses excellent communication and critical thinking skills, and is dedicated to upholding the highest standards of patient care and regulatory compliance.
• • You will be an integral part of Humana's commitment to putting health first, making a tangible difference in the lives of millions of individuals.
• • The position requires a proactive approach to staying abreast of evolving healthcare regulations and best practices in acute rehabilitation.