Medical Director - Humana Military - Tricare

Description

The Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Responsibilities

The Medical Director has a strong clinical background and reviews prior-authorization requests, claims, potential quality issues, and provides guidance on improving health outcomes and positively impacting cost trends.  A special emphasis is placed on active military service members, and their medical readiness.  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.

KEY ACCOUNTABILITIES

Leadership

Provide effective leadership, management, and associate coaching and development Provide meaningful input to the leadership decision making process on areas of health system management.
 

Physician and Health Care Professional Relations

Communicate with physicians and other health care professionals as needed to discuss care management issues or other issues related to the delivery of health care to the TRICARE or other government contracted beneficiaries. Assist in the recruitment and retention of physicians and other health care providers or systems into the Humana Government Business network. Provide health education opportunities for physicians and other health care providers on issues of significance to our patient population in a timely and professional manner.  Education may be provided in written, electronic, verbal or various other media. 

Utilization Management

Oversee utilization management activities provided during medical record/case review: Provide peer-to-peer communications, for clarification of issues related to medical necessity and other medical care or customer issues.  Provide medical necessity determinations for first level medical necessity approvals in conjunction with other health professional providing record/case review. Refer medical necessity determinations to second level reviewers/external review organization when unable to approve the health care for medical necessity. Provide peer-to-peer communications, for clarification of issues related to medical necessity and other medical care or customer issues. MTF notification/coordination for health care services as the need arise 

           

Monitor TRICARE’s cost for health care services delivered throughout the market area.  This involves regular review of cost of care initiatives, cost of care reports, and coordinating lower-cost alternatives with MTFs.Active participation in the UM committees and subcommittees. Support the corporately driven UM and Network accreditation process and all requirements and projects related to its success Review medical management data for trends on high frequency, high cost diseases which may benefit from pre-authorization requirements Use relevant peer reviewed data available in the literature, consult with Senior Medical Director and other processes to determine benefit coverage in instances where TRICARE policy is ambiguous or silent Leads implementation of initiatives developed within the organization that impact medical management in UM, Quality Improvement, . Review medical files and assist Program Integrity staff with clinical issues involving potential fraud and abuse.

                                                                                                                                              Case Management                                                                                                           

Serve as the first-line consultant for case management services in the market area        Review case management trends in geographic area and develop best practices strategies for addressing case management challenges Provide input into the review of medical cost trends in the area of case management and develop strategies to address areas in need of increased attention Education of case management nurses     Assist/Support Transplant case managers in reviewing selected cases for transplant    

Disease Management      

Develop significant familiarity in disease management in order to support HM disease management programs Respond to concerns of our network providers with the HM disease management program    

Medical Management Report Monitoring

Assist in the development of interventions using the various reports to a) manage the cost of care in order that expenditures reflect the delivery of only medically necessary health care in the HM networks and b) influence the delivery of medically necessary care to the TRICARE beneficiary Participate in the regular review of medical management reports                                  

Quality Management Program

Direct the clinical aspects of the clinical quality management program in the market area, coordinating activities with the regional QM staff as required.  Be the lead or an active participant in the identification of patient care quality issues specific to practitioners or facilities in their geographic area Implement corporately-developed HM medical policies and procedures related to the Clinical Quality Management Program (CQMP). Work closely with the QM nurse to assist in developing quality of care issues to present at the QM Committee and subcommittees Routinely review HM reports containing quality of care metrics for providers in the market area. Actively participate in QM committees and sub-committees Implement patient safety initiatives developed by Patient Safety Peer Review Committee, Actively participate, when required, in the support of HEDIS-like programs Participate in the regular review of medical management and quality management reports which influence the quality of health care delivery to the TRICARE beneficiary. Collaborate and guide QM nurses in the determination of cases with quality issues and advise on investigations Review quality of care provider issues and recommend changes in MSR ranking for steerage

Quality Management - Provider Relations

Communicate with providers as needed to discuss quality management issues

Quality Management Report Monitoring

Assist in the development of interventions using the various reports to influence the quality of health care delivery to the TRICARE beneficiary Participate in the regular review of quality management reports

Credentialing

Participate in the Credentialing Committee as a voting member Recruit as needed network physicians for participation in this committee.   Prior to the credentialing committee meeting, review the credentialing files of providers with issues Serve as Chair of Credentialing Committee as requested Assist in the evaluation of issues related to quality of care or service for specific providers during the re-credentialing phase or at other times as needed

               

Responsibilities

The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts.   The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines.  Supports the assigned work with respect to market-wide objectives (e.g. Bold Goal) and community relations as directed.

               

Required Qualifications

• MD or DO degree
• 5 years of direct clinical patient care experience post residency or fellowship,
• Current and ongoing Board Certification  an approved ABMS Medical Specialty
• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required.
• No current sanction from Federal or State Governmental organizations, and able to pass  credentialing requirements.
• Excellent verbal and written communication skills .
• Evidence of analytic and interpretation skills,  with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post acute services such as inpatient rehabilitation.
   

Preferred Qualifications

• Knowledge of the managed care industry including TRICARE, Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
• 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
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists
• Advanced degree such as an MBA, MHA, MPH
• Exposure to Public Health, Population Health, analytics, and use of business metrics.
• Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.
• The curiosity to learn, the flexibility to adapt and the courage to innovate
   

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

·         At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

·         Satellite, cellular and microwave connection can be used only if approved by leadership

·         Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

·         Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

·         Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

This is a remote position
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Scheduled Weekly Hours

40