Medical Director – Claims

🕒 April 16

🇺🇸 United States – Remote

💵 $223.8k - $313.1k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

⚕️ Healthcare Insurance

Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Make determinations whether to authorize requested services, request level of care, and requested site of service • 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 • Discussions with external physicians by phone to gather additional clinical information or discuss determinations • Possible participation in care management • Contribution to dispute and appeals reviews

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience post residency or fellowship • Current and ongoing Board Certification an approved ABMS or AOA Medical Specialty • Current and unrestricted license in at least one jurisdiction • Evidence of analytic and interpretation skills • Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and Commercial products • Utilization management experience in a medical management review organization • Experience with national guidelines such as MCG® or InterQual • Internal Medicine, Family Practice, Geriatrics, Hospitalist, and Emergency Medicine clinical specialists

🏖️ 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 and many other opportunities