Lead Medical Director, OneHome Expansion

Become a part of our caring community The Lead Medical Director relies on medical background and reviews health claims. The Lead Medical Director requires a solid understanding of how organization capabilities interrelate across department(s). TheLead Medical Director, OneHome Expansionprovides clinical and operational leadership for medical review activities supporting Home Health, Skilled Nursing Facility, Durable Medical Equipment, Medicare/Medicaid dual-eligible requests, and related home care solutions. Grounded in CMS Medicare guidance and applicable regulatory requirements, this role ensures consistent, timely, fair, compliant, and evidence-based medical necessity determinations for Medicare, Medicaid, and Dual Eligible populations. In partnership with clinical, operational, compliance, and Medicare business leaders, the Lead Medical Director supports OneHome Expansion initiatives, enhances medical management workflows, develops team performance, and contributes to CMS Star success through improved timeliness, fairness, and review quality. Leadership and Team Operations • Oversee daily operations of a team of Medical Directors conducting appeals and clinical case reviews for Medicare and Dual Eligible populations. • Maintain Medical Director staffing schedules, including paid time off, weekend coverage, after-hours coverage, and call rotation planning. • Lead regular team meetings and cross-functional meetings with internal stakeholders, operational partners, and leadership. • Foster development of Medical Directors through coaching, collaboration, education, and non-case review activities. • Support team engagement and promote a collaborative culture aligned with organizational excellence and Humana s leadership expectations. • Partner with the Director of Physician Leadership and other Lead Medical Directors to ensure consistency in processes, expectations, and performance. Clinical Case Review and Medical Necessity Determinations • Conduct clinical case reviews for approximately 50% of the role s responsibilities. • Review Medicare, Medicaid, and Dual Eligible member cases to determine medical necessity and appropriateness of requested services. • Evaluate requests related to home health, skilled nursing facility services, durable medical equipment, and other home-based care services. • Provide clinical interpretation and medical decisions regarding services requested or provided by other healthcare professionals. • Apply national clinical guidelines, CMS requirements, Humana policies, clinical standards, review procedures, and applicable contracts consistently. • Identify and resolve complex clinical, technical, and operational issues that arise during case review or appeals processes. Regulatory Compliance and Medicare Requirements • Ensure timely completion of clinical reviews and appeals to meet Medicare regulatory requirements. • Support compliance with CMS Medicare guidance, Medicare Advantage requirements, Medicaid requirements, and applicable federal and state laws. • Promote consistency, accuracy, fairness, and timeliness in medical necessity determinations. • Support team performance related to CMS Star measures, particularly Timeliness and Fairness measures. • Ensure all clinical review work is conducted within Humana s and OneHome s regulatory compliance framework. Cross-Functional Partnership and OneHome Expansion Support • Develop collaborative relationships with key partners across the Medicare Line of Business, Home Care Solutions, OneHome, internal operations teams, and leadership. • Serve as a clinical leader and subject matter resource for OneHome expansion activities. • Help align medical review practices with OneHome s operational model and Humana s broader Medicare and home care strategy. • Support implementation of processes that improve service delivery, member experience, provider collaboration, and operational efficiency. • Participate in meetings with business, clinical, operational, and compliance partners to address performance, process, and clinical review needs. Operational Improvement and Performance Management • Identify opportunities to improve medical management operations, workflow efficiency, review consistency, and case turnaround times. • Support process improvement efforts related to home health, skilled nursing facility, durable medical equipment, Medicare, Medicaid, and Dual Eligible requests. • Analyze clinical information and operational data to identify trends, risks, performance gaps, and opportunities for improvement. • Promote workflow efficiencies through effective use of technology, systems, and standardized review practices. • Contribute to scalable solutions that support OneHome expansion and the evolving needs of Medicare members. Education, Communication, and Clinical Expertise • Participate in required educational activities, clinical conferences, and internal learning forums. • Create and present education...