Northeast Regional Medical Director in New York, New York | DiversityInc Careers
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Northeast Regional Medical Director

Role: Northeast Regional Medical Director

Assignment: Senior Segment

Location: New York, NY

Clinical Guidance: Make a difference in people’s lives

Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide a perfect experience with one-on-one interactions as a coach, personal nurse, or clinical advisor.

Humana’s Perfect Experience® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members and providers. We want to help our members make the right choices to live life fully. We begin that process by connecting them with an associate who cares.

Assignment Capsule

Be a part of our Clinical Operations team that’s dedicated to improving the health and well-being of our members, our associates, the communities we serve, and our planet.

Humana is seeking a Regional Medical Director that will collaborate with other health care givers in reviewing actual and proposed medical care services against established CMS, DOI, Humana and other nationally recognized and accepted guidelines.

As a Regional Medical Director you will provide medical leadership and strategy for the Health Services Operations with fiscal responsibility for trend management.

  • Oversee regional utilization management and case management for inpatient cases (acute care hospital, LTAC, Acute rehab, SNF) according to the Humana Medicare Model of Care.
  • Participate in Quality Operations including chair Quality Management Committee, complete initial peer review on quality of care complaints, complete peer-to-peer written and verbal communications.
  • Oversee administrative budget for regional HSO & Quality Improvement including approve/deny expense reports & requisition requests for department members.
  • Oversee Quality Improvement and HEDIS/STARS metrics improvement with PCP offices and IPAs.
  • Participate in regional level committees and meetings setting medical necessity strategies.
  • Provide oversight and direction for the implementation of regional clinical programs and strategies, as well as, developing and implementing market level strategies.
  • Manage internal operational/functional relationships related to profitability.
  • Assist with network development and provider contracting with various providers and ancillary providers.
  • Serve as clinical liaison with inpatient facilities and joint operating committees to maintain facility relationship and problem solve; especially reviewing contracts as to clinical services.
  • Well-versed on financial aspects of various levels of risk bearing contracts and possess the ability to gain traction and adoption of the providers.
  • Ability to thrive in a highly matrix environment.
  • Assist with overflow review in unusual circumstances.

Reporting Relationships

You will report to a Regional President. This area is under the leadership of the Division President.

Role Essentials

  • MD/DO Board Certified in an ABMS Medical Specialty
  • Active unrestricted medical license
  • 5+ years clinical practice experience with strong knowledge of the managed care industry
  • Experience in community based and chronic disease management
  • Visibility and involvement in medical community
  • Previous Medicare/Medicaid experience
  • Previous experience leading teams focusing on utilization management, discharge planning and/or home health or rehab
  • Supervisory skills including clinical mentoring and coaching
  • Excellent presentation and analytical skills
  • Exceptional written and oral communication skills to a wide range of associates (front-line to leaders) and both internal and external audiences
  • Ability to rapidly build positive relationships with consumers, employers, and providers at all levels in the marketplace

Role Desirables

  • Board Certification in Internal Medicine, Family Practice or Geriatrics

Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.