Medical Director

• Provide clinical leadership for utilization management programs
• Set UM strategy aligned with organizational goals
• Serve as senior clinical advisor to executive leadership on utilization trends
• Oversee the medical policy team
• Lead the Medical Policy and Utilization Management Governance Committees
• Oversee complex and high-risk utilization review cases
• Conduct clinical reviews and peer-to-peer reviews
• Ensure consistent, evidence-based application of clinical guidelines
• Provide clinical expertise to teams conducting coding and payment integrity
• Act as senior clinical UM liaison to network providers
• Build and maintain strong physician relationships
• Lead development and implementation of UM interventions
• Review utilization data for improvement opportunities
• Ensure UM programs meet regulatory requirements
• Conduct and support training of medical directors and UM staff

Senior Medical Director

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making
• Supports effective implementation of performance improvement initiatives for capitated providers
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Participates in provider network development and new market expansion as appropriate
• Assists in the development and implementation of physician education with respect to clinical issues and policies
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
• Develops alliances with the provider community through the development and implementation of the medical management programs
• May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues
• Represents the business unit at appropriate state committees and other ad hoc committees
• May be required to work weekends and holidays in support of business operations, as needed

• Provide clinical interpretation and determinations on the medical appropriateness of services delivered by healthcare professionals, including the application of evidence-based guidelines.
• Make independent, timely, and defensible medical decisions on complex appeal cases, exercising professional judgment with minimal supervision.
• Collaborate with cross-functional teams—including legal, compliance, and clinical operations—to address and resolve grievances and appeals.
• Participate in quality improvement initiatives, identifying trends in grievances and appeals and recommending process improvements.
• Serve as a clinical resource for grievance and appeals staff, providing guidance and education as needed.
• Maintain current knowledge of Medicare regulations, managed care requirements, and industry best practices relevant to appeals and grievances.
• Support Humana’s commitment to continuous improvement in consumer experience, ensuring fair, consistent, and customer-focused outcomes.
• Participate in internal and external audits as required and respond to regulatory inquiries as needed.
• Adhere to all confidentiality and HIPAA requirements in handling protected health information (PHI).

Medical Director – Grievances & Appeals

• Assist the Chief Medical Director to direct and coordinate medical management, quality improvement and credentialing functions
• Provides medical leadership for utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and complex medical services
• Supports effective implementation of performance improvement initiatives for capitated providers
• Assists in planning and establishing goals and policies to improve quality and cost-effectiveness of care
• Provides medical expertise in operation of approved quality improvement and utilization management programs
• Assists in the functioning of physician committees
• Conducts regular rounds to assess and coordinate care for high-risk patients
• Collaborates with clinical teams, network providers, and medical consultants for reviewing complex cases
• Participates in provider network development and market expansion
• Develops and implements physician education with respect to clinical issues

Medical Director, Appeals

• Medical Director responsible for the administration of physical and/or behavioral health medical services.
• Ensure the appropriate and most cost-effective medical care is received.
• May be responsible for developing and implementing programs to improve quality, cost, and outcomes.
• Provides clinical consultation and serves as clinical/strategic advisor.
• Identifies cost of care opportunities.
• Serves as a resource to staff including Medical Director Associates.
• Conducts peer-to-peer clinical reviews and may represent the company to external entities and/or serve on committees.

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services
• Supports effective implementation of performance improvement initiatives for capitated providers
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Provides medical expertise in the operation of approved quality improvement and utilization management programs
• Assists the Chief Medical Director in the functioning of the physician committees
• Conduct regular rounds to assess and coordinate care for high-risk patients
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Participates in provider network development and new market expansion as appropriate
• Assists in the development and implementation of physician education with respect to clinical issues and policies
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
• Develops alliances with the provider community through the development and implementation of the medical management programs
• May represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues
• May be required to work weekends and holidays in support of business operations, as needed

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making
• Supports effective implementation of performance improvement initiatives for capitated providers
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Participates in provider network development and new market expansion as appropriate
• Assists in the development and implementation of physician education with respect to clinical issues and policies
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
• Develops alliances with the provider community through the development and implementation of the medical management programs
• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues
• Represents the business unit at appropriate state committees and other ad hoc committees
• May be required to work weekends and holidays in support of business operations, as needed

National Medical Director

• Responsible for the administration of physical and/or behavioral health medical services
• Supports clinicians to ensure timely and consistent responses to members and providers
• Conducts peer-to-peer clinical reviews
• Identifies and develops opportunities for innovation to increase effectiveness and quality

Medical Director – Family/Internal Medicine

• Provide medical consultation in transfusion medicine, blood banking, and patient services to hospital clients, fostering strong and collaborative relationships.
• Deliver continuing medical education to internal and external audiences, promoting safe and effective use of blood components.
• Lead patient service programs such as therapeutic apheresis, stem cell collection and processing, perioperative autologous cell salvage, and patient blood management.
• Oversee medical aspects of regulated blood center operations including donor management, recipient adverse reactions, and product investigations.
• Contribute to the development of policies and procedures related to donor eligibility, component quality, and transfusion practices.
• Serve as CLIA Laboratory Director for regulated collection activities and laboratories including immunohematology, HLA, stem cell, and national testing labs.
• Investigate donor and recipient concerns, transfusion-related issues, and customer service complaints, ensuring timely resolution and appropriate leadership notification.
• Support, mentor, and guide volunteers to enhance their contributions and professional development.

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