Medical Director - South Carolina SE Region
- OREGON EMPLOYMENT DEPARTMENT
- Salem, Massachusetts
- Full Time
Job Listing ID: 4316438 Job Title: Medical Director - South Carolina SE Region
Application Deadline: Open Until FilledJob Location: Salem
Date Posted: 07/24/2025Hours Worked Per Week: Not Provided
Shift: Not Provided
Duration of Job: Either Full or Part Time, more than 6 months
You may contact this employer directly.
(Obtain the contact information to print or add to your jobs.)
Job Summary:
Become a part of our caring community and help us put health first
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.
Description
The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work.
The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value based care, population health, or disease or care management.
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 structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines.
Use your skills to make an impact
Required Qualifications
MD or DO degree
Must have or be able obtain South Carolina medical license
Occasional weekend work is required
5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age).
Current and ongoing Board Certification in an approved ABMS Medical Specialty
A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), 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 participat...
Job Classification: Medical and Health Services Managers
Access our statewide or regional occupation report for more information about wages,
employment outlooks, skills, training programs, related occupations, and more.
Compensation
Salary: Not Provided
Job Requirements
Experience Required: See Job Summary
Education Required: NoneMinimum Age: N/A
Gender: N/A
Application Deadline: Open Until FilledJob Location: Salem
Date Posted: 07/24/2025Hours Worked Per Week: Not Provided
Shift: Not Provided
Duration of Job: Either Full or Part Time, more than 6 months
You may contact this employer directly.
(Obtain the contact information to print or add to your jobs.)
Job Summary:
Become a part of our caring community and help us put health first
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.
Description
The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work.
The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value based care, population health, or disease or care management.
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 structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines.
Use your skills to make an impact
Required Qualifications
MD or DO degree
Must have or be able obtain South Carolina medical license
Occasional weekend work is required
5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age).
Current and ongoing Board Certification in an approved ABMS Medical Specialty
A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), 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 participat...
Job Classification: Medical and Health Services Managers
Access our statewide or regional occupation report for more information about wages,
employment outlooks, skills, training programs, related occupations, and more.
Compensation
Salary: Not Provided
Job Requirements
Experience Required: See Job Summary
Education Required: NoneMinimum Age: N/A
Gender: N/A
Job ID: 486983172
Originally Posted on: 7/26/2025
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