Medical Director – IP Claims Management

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CenterWell Senior Primary Care

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Healthcare Insurance

CenterWell Senior Primary Care is a healthcare provider focused on delivering personalized primary care to senior citizens. The company emphasizes a comprehensive and holistic approach to healthcare, addressing the physical, social, and emotional needs of older adults. As part of its service offerings, CenterWell includes home health services and pharmacy support to complement its senior primary care. The organization is committed to offering stability, inclusive benefits, and career growth opportunities for its employees while maintaining a culture of mutual respect and mindfulness. CenterWell is a brand under the larger healthcare entity, Humana.

1001 - 5000 employees

⚕️ Healthcare Insurance

📋 Description

• actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. • learn Medicare, Medicare Advantage, and Medicaid requirements and will understand how to operationalize this knowledge in their daily work. • includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. • May occasionally participate in discussions with external physicians by phone to gather additional clinical information or discuss determinations which may require conflict resolution skills. • Some roles include an overview of coding practices and clinical documentation, dispute, grievance, and appeals processes, and outpatient services and equipment, within their scope. • may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value-based care, population health, or disease or care management. • support Humana values throughout all activities.

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age). • Current and ongoing Board Certification an approved ABMS Medical Specialty • A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), if required. • No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. • Excellent verbal and written communication skills. • Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation.

🏖️ Benefits

• medical, dental and vision benefits • 401(k) retirement savings plan • time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave) • short-term and long-term disability • life insurance • many other opportunities