Medical Director – Payment Integrity

🔥 17 hours ago

🇺🇸 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

• 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 Inpatient level. • Provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. • Supports and collaborates with other team members, other departments, Humana colleagues and the Lead Medical Director. • Conducts post-service, inpatient care reviews for accurate billing of clinically valid diagnoses and care received. • Engages in disputes and grievance and appeals reviews. • Participates on project teams or organizational committees.

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes 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, 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, paid parental and caregiver leave) • short-term and long-term disability • life insurance and many other opportunities