Medical Director – Grievances & Appeals

🕒 May 19

🏄 California, Illinois, +2 more states – Remote

🏄 California – Remote 🌽 Illinois – Remote 🦬 Montana – Remote 🗿 South Dakota – Remote

💵 $246.1k - $344.2k / 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

• Provide clinical interpretation and determinations on the medical appropriateness of services delivered by healthcare professionals, including the application of evidence-based guidelines. • Make independent, timely, and defensible medical decisions on complex appeal cases, exercising professional judgment with minimal supervision. • Collaborate with cross-functional teams—including legal, compliance, and clinical operations—to address and resolve grievances and appeals. • Participate in quality improvement initiatives, identifying trends in grievances and appeals and recommending process improvements. • Serve as a clinical resource for grievance and appeals staff, providing guidance and education as needed. • Maintain current knowledge of Medicare regulations, managed care requirements, and industry best practices relevant to appeals and grievances. • Support Humana’s commitment to continuous improvement in consumer experience, ensuring fair, consistent, and customer-focused outcomes. • Participate in internal and external audits as required and respond to regulatory inquiries as needed. • Adhere to all confidentiality and HIPAA requirements in handling protected health information (PHI).

🎯 Requirements

• MD or DO degree completed at an accredited university in the USA • A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment • Board Certified in an approved ABMS/ABOA Medical Specialty • 5 years of established clinical experience • Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products • Possess analysis and interpretation skills with prior experience leading teams focusing on quality management. • Experience with discharge planning and/or home health or rehab

🏖️ 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