Job Description
Become a part of our caring community The Medical Director relies on medical background and reviews health claims. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. Join a distinguished team of physicians dedicated to advancing the quality of inpatient care through clinical expertise and thoughtful medical necessity review. This position is well-suited for physicians who excel in case analysis, structured decision-making, and collaboration, offering an opportunity to impact patient outcomes without the physical demands or irregular hours of bedside care. Physicians with backgrounds in Hospital Medicine, Critical Care, Emergency Medicine, or those experienced in Utilization Review are encouraged to apply. Role Overview Perform expert clinical review of inpatient medical records, assessing medical necessity based on national guidelines, CMS regulations, Humana policies, and recognized clinical standards. Analyze complex hospital-based cases and deliver clear, well-reasoned utilization management determinations. Communicate with external providers via phone to obtain clinical information and discuss review outcomes. Collaborate within a structured, team-oriented environment that emphasizes integrity, professionalism, and collegiality. Advance Humana's mission by supporting high-quality, consistent decision-making and fostering strong physician partnerships. Responsibilities Conduct inpatient medical necessity reviews promptly and in accordance with regulatory requirements. Uphold excellence in productivity, accuracy, quality, and timely completion of assigned tasks. Communicate review outcomes clearly and profess