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. TheCorporate Medical Director, OneHome Expansionprovides 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 clinical scenarios and variable factors to determine the most appropriate course of action. Strategic Medical Leadership • Advise executives and business leaders on functional strategies related to OneHome Expansion and segment-specific clinical priorities. • Serve as a clinical subject matter expert on matters of significance involving home-based care, post-acute services, utilization management, quality management, discharge planning, and care coordination. • Exercise independent judgment and decision-making on complex issues related to clinical review operations and medical management strategy. • Support the development and refinement of policies, procedures, workflows, and performance standards that improve review quality and operational consistency. • Contribute to scalable strategies that support OneHome Expansion and the evolving needs of Medicare, Medicaid, Commercial, and dual-eligible populations. Operational Improvement and Performance Support • Identify opportunities to improve medical management operations, workflow efficiency, case turnaround times, review consistency, and service delivery. • Analyze clinical information, utilization patterns, operational data, and performance trends to identify gaps, risks, and opportunities. • Support initiatives focused on quality management, utilization management, discharge planning, home care solutions, rehabilitation, and post-acute care performance. • Partner with operational teams to simplify processes, reduce unnecessary complexity, and improve consistency across review activities. • Promote the use of technology, standardized workflows, and data-driven decision-making to enhance operational effectiveness. Regulatory Compliance and Review Standards • Ensure clinical review activities comply with applicable federal and state laws, CMS guidance, Medicare Advantage requirements, Medicaid requirements, Humana policies, and contractual obligations. • Support adherence to review policies, procedures, performance standards, and regulatory timelines. • Promote compliance-focused decision-making across clinical review and medical management activities. • Help ensure determinations are supported by appropriate documentation, clinical rationale, and evidence-based standards. • Identify and escalate regulatory, clinical, or operational concerns as appropriate. Cross-Functional Collaboration • Partner with leaders and stakeholders across OneHome, Home Care Solutions, Medicare, Medicaid, Commercial, clinical operations, compliance, quality, and utilization management. • Collaborate with teams focused on provider engagement, member experience, care coordination, discharge planning, rehabilitation, and home care solutions operations. • Translate complex clinical, regulatory, and policy requirements into clear guidance for business and operational partners. • Participate in meetings, workgroups, and strategic initiatives to address clinical review needs, operational b...