医疗主任 - OneHome
Medical Director - OneHome
成为我们关怀社区的一员
医学主任依靠CMS Medicare指导原则，对居家护理、SNF、DME以及双重Medicare/Medicaid请求进行跟进和审查。医学主任审查并确定其他医疗专业人员提供的医疗服务是否符合国家指南、CMS要求、Humana政策、临床标准和适用合同。医学主任评估医疗服务的医疗必要性，确保决策符合监管和组织标准。该职位需要解读临床指南、CMS政策和Medicare要求，并一致地应用这些内容。OneHome的所有工作均在合规框架内进行，这确保了符合联邦和州法律的所有要求。医学主任审查Medicare和Medicaid成员的临床案例，向首席医学主任汇报，并在规定的时限和部门期望内工作。
岗位职责：
- 审查临床案例，确定Medicare和Medicaid成员的服务医疗必要性。
- 确保符合审查政策、程序和监管标准。
- 应用临床指南、CMS政策和Medicare/Medicare Advantage/Medicaid要求。
- 识别医疗管理操作改进的机会。
- 参与值班轮换，包括周末和非工作时间的值班。
- 参与一个积极、协作的团队文化，支持组织卓越。
- 提供卓越的客户体验。
- 通过参加必要的会议和创建内容进行教育活动，为特定主题贡献个人专业知识。
- 支持Home Solutions和其他由OneHome领导分配的活动。
运用你的技能产生影响
所需资格
- 医学博士（MD）或骨科医学博士（DO）学位
- 当前、有效且持续的美国医学专科委员会（ABMS）或美国骨科医学协会骨科专科委员会（AOABPS）认证。不接受国家医师与外科医生委员会（NBPAS）认证。
- 在至少一个州拥有当前且无限制的执业执照，并愿意根据分配地区的不同，获得其他州的医疗执照。
- 无联邦或州政府机构的制裁记录
- 5年直接的临床患者护理经验
查看英文原文
Become a part of our caring community
The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing Home Health, SNF, DME, dual Medicare/Medicaid requests. The Medical Director reviews and determines whether healthcare services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and applicable contracts.The Medical Director evaluates the medical necessity of healthcare services, ensuring decisions comply with regulatory and organizational standards. The role requires interpreting clinical guidelines, CMS policies, and Medicare requirements, and applying them consistently. All work at OneHome is conducted within a framework of regulatory compliance. This secures compliance with all requirements set by federal and state laws. Medical Directors review clinical cases for Medicare and Medicaid members, report to the Lead Medical Director, and work within defined timelines and departmental expectations.
Role Responsibilities:
- Review clinical cases and determine medical necessity of services for Medicare and Medicaid members.
- Ensure compliance with review policies, procedures, and regulatory standards.
- Apply clinical guidelines, CMS policies, and Medicare/Medicare Advantage/Medicaid requirements.
- Identify opportunities for medical management operational improvements.
- Participate in call rotations, including weekend coverage and after-hours coverage.
- Contribute to an engaged, collaborative team culture that supports organizational excellence.
- Deliver exceptional consumer experiences.
- Participate in educational activities by attending required conferences and creating content to present for individual subject matter contribution.
- Support Home Solutions and other activities as assigned by the OneHome leadership.
Use your skills to make an impact
Required Qualifications
- MD or DO degree
- Current, active and ongoing board certification from the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialties (AOABPS). National Board of Physicians & Surgeons (NBPAS) certification is not accepted.
- Current and unrestricted state license in at least one state and willing to obtain other medical licenses, as required, for various states in region of assignment.
- No sanctions from Federal or State Governmental organizations
- 5 years of direct clinical patient care experience post residency or fellowship.
- The ability to pass credentialing requirements.
- Intermediate to advanced skills utilizing Microsoft Office and Internet navigation.
- Strong verbal and written communication skills, with the ability to analyze information and interpret data clearly and accurately.
- Adaptable and willing to learn new technologies to enhance workflow efficiency.
Preferred Qualifications
- Experience in an inpatient and/or outpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age).
- Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, Surgery or hospital based clinical specialists.
Additional Information
- Workstyle: Remote work at home
- Hours: Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, call rotations, including weekend coverage and after-hours coverage. Must be able to work in local/residing time zone post-training.
- Training: 5 weeks of onboarding, no time off and training is in Eastern Standard Time (EST).
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$223,800 - $313,100 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Originally posted on Himalayas