Humana Reviewing Medical Director- Mid-Atlantic - WAH in Glen Allen, Virginia

Role: Mid-Atlantic Medical Director Assignment:Senior Segment Location: WAH

Are 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 Capsule

In this role you will be responsible for covering the Mid-Atlantic Region (VA, DE, MD, NC). Travel would be approximately 15% of the time.

You will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS, DOI, Humana and other nationally recognized and accepted guidelines. * Provide physician review services for utilization management, case management, quality management, and conduct peer to peer reviews

  • Develop, maintain and assure compliance with physician review policies and procedures (including timeliness) for utilization management and support case management.

  • Support collaborative relationships with physicians, large provider groups, hospitals, other facilities and ancillary providers.

  • 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, post-discharge and discharge planning with clinical staff and peers

  • Onsite rounding with clinical staff to support utilization and case management Key Competencies

  • Leveraging 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 programs

  • Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.

Role Essentials * A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment

  • MD or DO degree

  • Board Certified

  • Five years clinical experience

  • Excellent communication skills Role Desirables

  • Health Plan Experience

  • Prior experience as Associate Medical Director (or equivalent) or physician reviewer in a Managed Care Plan

  • Previous Medicare/Medicaid experience

  • Previous experience leading teams focusing on utilization management, discharge planning and/or home health or rehab

  • MD License in VA is preferred but not mandatory

  • Bilingual


Title: Reviewing Medical Director- Mid-Atlantic - WAH

Location: Virginia-Glen Allen

Other Locations: US-Virginia-Richmond, US-KY-Louisville, US-Delaware, US-Virginia, US-North Carolina, US, US-Maryland

Requisition ID: 179206

Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.