Medical Director – PI, Claims

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🔥 0 minutes 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

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 medical interpretation and clinical determinations regarding whether services provided by healthcare professionals align with applicable national guidelines, CMS requirements, Humana policies, clinical standards, and relevant contract requirements • Review clinical information and apply evidence-based criteria to support consistent, compliant, and well-documented medical decisions • Collaborate with team members, cross-functional departments, Humana colleagues, and the Regional VP of Health Services to support departmental and market-wide objectives • Perform daily work with minimal direction after completion of mentored training, while maintaining alignment with departmental standards and expectations • Work effectively in a structured environment that requires consistency in clinical reasoning, decision-making, documentation, and authorship • Exercise independent judgment in meeting departmental expectations, operational goals, and compliance timelines • Support market-wide health objectives, including initiatives such as Bold Goal, and contribute to community relations activities as directed • Partner with internal stakeholders to promote quality outcomes, appropriate utilization, and adherence to clinical and regulatory requirements • Maintain current knowledge of applicable clinical standards, regulatory guidance, CMS requirements, and organizational policies relevant to medical decision-making • Communicate clinical determinations clearly and professionally to appropriate internal and external stakeholders • Contribute to process consistency, quality improvement, and operational effectiveness within the assigned area of responsibility • Demonstrate professionalism, accountability, and collaboration in support of Humana’s clinical, compliance, and business objectives

🎯 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 in 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 onboarding 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