CenterWell Pharmacy, Inc. is looking for a Medical Director, National OP Medicare to join our team. In this role, you will review preauthorization requests for services, making determinations based on your medical background, clinical guidelines, and CMS policies. You'll be a key part of ensuring appropriate care delivery.
What You'll Do
- Review preauthorization requests for services, level of care, and site of service using medical background and clinical judgment.
- Conduct computer-based review of moderately complex to complex clinical scenarios and review all submitted clinical records.
- Communicate decisions to internal associates and participate in care management as needed.
- Have discussions with external physicians by phone to gather additional clinical information or discuss determinations.
- Provide medical interpretation to determine if services align with national guidelines, CMS requirements, and company policies.
- May speak with contracted external physicians, groups, or facilities to support regional market priorities.
- May participate in grievance and appeals reviews, project teams, or organizational committees.
What We're Looking For
- MD or DO degree.
- 5+ years of direct clinical patient care experience post residency or fellowship.
- Current and ongoing Board Certification in an approved ABMS Medical Specialty.
- A current and unrestricted license in at least one jurisdiction and willingness to obtain additional licenses, if required.
- No current sanction from Federal or State Governmental organizations, and ability to pass credentialing requirements.
- Excellent verbal and written communication skills.
- Evidence of analytic and interpretation skills.
- The curiosity to learn, the flexibility to adapt, and the courage to innovate.
Nice to Have
- Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid.
- Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance.
- Experience with national guidelines such as MCG® or InterQual.
- Advanced degree such as an MBA, MHA, or MPH.
- Exposure to Public Health, Population Health, analytics, and the use of business metrics.
- Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.
Team & Environment
This role typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director.
Benefits & Compensation
- Medical, dental and vision benefits.
- 401(k) retirement savings plan.
- Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave).
- Short-term and long-term disability.
- Life insurance.
- Compensation range: $223,800 - $313,100 per year.
Work Mode
This is a remote position.
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.
