Medical Director – Payment Integrity

🕒 July 31

🇺🇸 United States – Remote

💵 $223.8k - $313.1k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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👻 Ghost score 26%

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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 determinations whether requested services, requested level of care, and/or requested site of service should be authorized at the Inpatient level • Conduct computer-based reviews of moderately complex to complex clinical scenarios • Review all submitted clinical records • Prioritize daily work and communicate decisions to internal associates • Conduct medical interpretation and determinations against national guidelines, CMS requirements, Humana policies, clinical standards, and contracts where applicable • Collaborate with team members, departments, Humana colleagues, and the Lead Medical Director • Perform daily work independently with minimal direction after mentored training • Meet departmental expectations, compliance timelines, and consistency requirements • Support market-wide objectives and community relations • Conduct post-service inpatient care reviews for accurate billing of clinically valid diagnoses and care received • Engage in disputes, grievance, and appeals reviews • Participate on project teams or organizational committees

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience post residency or fellowship • Current and ongoing Board Certification in an approved ABMS Medical Specialty • Current and unrestricted license in at least one jurisdiction, with willingness to obtain additional license if required • No current sanction from Federal or State Governmental organizations • Ability to pass credentialing requirements • Excellent verbal and written communication skills • Evidence of analytic and interpretation skills • Prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services • Knowledge of the managed care industry, Medicare Advantage, Managed Medicaid and/or Commercial products, or related healthcare organizations (preferred) • Utilization management experience in a medical management review organization (preferred) • Experience with national guidelines such as MCG® or InterQual (preferred) • Clinical specialization in Internal Medicine, Hospitalist, Family Practice, Geriatrics, or Emergency Medicine (preferred) • Advanced degree such as an MBA, MHA, or MPH (preferred) • Exposure to Public Health, Population Health, analytics, and business metrics (preferred)

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Personal wellness and smart healthcare decision support • Occasional travel to Humana offices for training or meetings may be required