Medical Director – OP Claims Management

November 25

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Humana

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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.

10,000+ employees

Founded 1961

⚕️ Healthcare Insurance

📋 Description

• The Medical Director 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 at the Initial and Appeals/Disputes level • All work occurs within a context of regulatory compliance, and work is assisted by diverse resources. • Medical Directors will learn Medicare, Medicaid, and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work • The Medical Director’s 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 • Discuss with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances may require conflict resolution skills.

🎯 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/outpatient 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, 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