Das ist der Job
All work at OneHome is conducted within a framework of regulatory compliance.
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The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing Home Health, SNF, DME, dual Medicare/Medicaid requests.
The Medical Director reviews and determines whether healthcare services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and applicable contracts.
The Medical Director evaluates the medical necessity of healthcare services, ensuring decisions comply with regulatory and organizational standards. The role requires interpreting clinical guidelines, CMS policies, and Medicare requirements, and applying them consistently. This secures compliance with all requirements set by federal and state laws.
Medical Directors review clinical cases for Medicare and Medicaid members, report to the Lead Medical Director, and work within defined timelines and departmental expectations. Role Responsibilities:
Review clinical cases and determine medical necessity of services for Medicare and Medicaid members.
Ensure compliance with review policies, procedures, and regulatory standards. Apply clinical guidelines, CMS policies, and Medicare/Medicare Advantage/Medicaid requirements. Identify opportunities for medical management operational improvements.
