Medical Director, Claims

🕒 August 7

🇺🇸 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

• Make medical determinations about authorization of requested services, level of care, and site of service at Initial or Appeals/Disputes level • Conduct computer-based reviews of moderately complex to complex clinical scenarios • Review submitted clinical records and prioritize daily work • Communicate decisions to internal associates • Participate in care management when applicable • Discuss determinations and resolve conflicts when needed • Review coding practices, clinical documentation, grievance and appeals processes, outpatient services, and equipment within scope • Speak with physicians, nurses, and internal collaborating groups • Provide medical interpretation and determinations against national guidelines, CMS requirements, Humana policies, clinical standards, and contracts where applicable • Conduct Utilization Management for members in an assigned market, member population, or condition type • Contribute to dispute and appeals reviews • Participate on project teams or organizational committees • Report to the Lead Medical Director

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience after residency or fellowship, including inpatient and/or outpatient experience • Experience caring for a Medicare-type population, such as disabled individuals or people over 65 • Current and ongoing board certification in an approved ABMS or AOA medical specialty • Current and unrestricted medical license in at least one jurisdiction • Willingness to obtain additional licenses • No current sanction from federal or state governmental organizations • Ability to pass credentialing requirements • Evidence of analytic and interpretation skills • Prior experience with quality management, utilization management, case management, discharge planning, and home health or post-acute services such as inpatient rehabilitation • Knowledge of the managed care industry, including Medicare Advantage, Managed Medicaid, Commercial products, medical management organizations, hospitals/integrated delivery systems, health insurance, healthcare providers, and clinical group practice management • Utilization management experience in a medical management review organization • Experience with national guidelines such as MCG® or InterQual • Clinical specialty background in Internal Medicine, Family Practice, Geriatrics, Hospitalist, or Emergency Medicine • Preferred: multiple licenses • Preferred: exposure to Public Health, Population Health, analytics, and business metrics • Preferred: experience with Medicare Advantage and Medicaid Claims medical reviews • Preferred: experience working with Case Managers or Care Managers on complex case management, including familiarity with social determinants of health • Minimum home internet speed of 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical benefits • Dental benefits • Vision benefits • 401(k) retirement savings plan • Paid time off • Company holidays • Personal holidays • Paid parental leave • Paid caregiver leave • Short-term disability • Long-term disability • Life insurance • Dedicated work-from-home space • Remote work arrangement • Occasional travel to Humana's offices for training or meetings