Corporate Medical Director, OneHome Expansion

Become a part of our caring community The Corporate 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. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, Uses independent judgment requiring analysis of variable factors and determining the best course of action. The Corporate Medical Director, OneHome Expansion provides medical interpretation, clinical review, and strategic medical leadership to support Humana ’s OneHome Expansion initiatives. This role reviews health claims and clinical requests to determine the appropriateness and medical necessity of services provided by healthcare professionals, including Home Care Solutions, Skilled Nursing Facility, Durable Medical Equipment, rehabilitation, discharge planning, and related home care solutions. Clinical Review and Medical Necessity Determinations Review clinical cases, health claims, and service requests to determine the medical necessity and appropriateness of care provided by healthcare professionals. Evaluate requests involving Home Care Solutions, Skilled Nursing Facility services, Durable Medical Equipment, rehabilitation, discharge planning, and other home-based care solutions. Apply CMS Medicare guidance, Medicare Advantage requirements, Medicaid requirements, national clinical guidelines, Humana policies, clinical standards, review procedures, performance standards, and applicable contracts. Provide medical interpretation and clinical rationale for determinations involving Medicare, Medicaid, Commercial, and dual-eligible populations, as applicable. Ensure decisions are timely, fair, consistent, compliant, and evidence-based. Analyze complex c