Medical Director – Grievances & Appeals

🕒 2 days ago

🇺🇸 United States – 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 • Make independent, timely, and defensible medical decisions on complex appeal cases • Collaborate with cross-functional teams—including legal, compliance, and clinical operations • Participate in quality improvement initiatives, identifying trends in grievances and appeals • Serve as a clinical resource for grievance and appeals staff • Maintain current knowledge of Medicare regulations, managed care requirements, and industry best practices

🎯 Requirements

• MD or DO degree completed at an accredited university in the USA • A current and unencumbered license in at least one jurisdiction • Board Certified in an approved ABMS/ABOA Medical Specialty • 5 years post residency of established clinical experience • Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products • 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, paid parental and caregiver leave) • short-term and long-term disability • life insurance