The Medical Director uses their medical background, experience, and judgement. You will make determinations whether they should authorize requested services, request level of care, and requested site of service at the Initial or Appeals/Disputes level. All work occurs within a context of regulatory compliance. Diverse resources assist work, including national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. You will learn Medicare, Medicaid, and Medicare Advantage requirements and understand how to operationalize this knowledge in their daily work.
Your work includes computer-based review of moderately complex to complex clinical scenarios. This work also includes review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. The clinical scenarios predominantly arise from inpatient, outpatient, or post-acute care environments. You will have discussions for determinations, and in some instances, these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
You may speak with physicians, nurses, internal collaborating groups to support organizational priorities. These priorities may include an understanding of Humana processes, and a focus on collaborative business relationships, values-based care, population health, or disease or care management.
