Medicaid Medical Director — Utilization & Care Leadership

Humana; Providence (RI); On-site; USD 223,800 - 313,100; Full time

Job summary

Humana is seeking a Medical Director to join our compassionate team in Providence, RI. In this crucial role, you will utilize your medical expertise to review health claims and address complex clinical scenarios while ensuring regulatory compliance.

Your responsibilities will include engaging in utilization management, collaborating with internal teams, and determining the medical necessity of services provided. The ideal candidate will have an MD or DO degree, Board Certification, and significant clinical experience.

This position offers a salary range of $223,800 - $313,100, with potential bonuses based on performance.

Qualifications

• Minimum of 5 years of clinical patient care experience, preferably in a Medicaid context.
• No current sanctions from Federal or State governments.

Responsibilities

• Determine medical necessity of services provided against established guidelines.
• Collaborate with various teams and support the Regional VP of Health Services.
• Participate in grievance and appeals reviews as necessary.

Skills

Medical necessity determination

Utilization management

Clinical record assessment

Conflict resolution

Education

MD or DO degree with Board Certification

Valid medical license in Florida

Advanced degrees (MBA or MHA) as a plus

Job description

Humana is seeking a Medical Director to join our compassionate team in Providence, RI. In this crucial role, you will utilize your medical expertise to review health claims and address complex clinical scenarios while ensuring regulatory compliance.

Your responsibilities will include engaging in utilization management, collaborating with internal teams, and determining the medical necessity of services provided. The ideal candidate will have an MD or DO degree, Board Certification, and significant clinical experience.

This position offers a salary range of $223,800 - $313,100, with potential bonuses based on performance.