Corporate Medical Director

Clinical Review and Medical Necessity Determinations:

• Review clinical cases, health claims, and service requests to determine 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, and applicable contracts.

Strategic Medical Leadership:

• Advise executives and business leaders on functional strategies related to OneHome 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.

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.