Medicare Grievances and Appeals Corporate Medical Director

Become a part of our caring community and help us put health first

The Corporate Medical Director relies on medical background and reviews health claims and preservice appeals. The Corporate Medical Director reviews cases of diverse scope and complexity ranging from moderate to substantial.

The Corporate Medical Director reviews medical necessity and appropriateness of services rendered by healthcare professionals in compliance with CMS guidelines, clinical coverage criteria, and quality standards. Represents Humana at Administrative Law Judge hearings. Exercises clinical judgment and independent decision making on complex case reviews, works under minimal supervision; and partners with clinical peers and leaders to meet team's business goals.

Schedule is Monday-Friday with intermittent weekend shift responsibilities (with offered comp days off)

Required Qualifications

Use your skills to make an impact

• MD or DO degree
• A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment
• Board Certified in an approved ABMS Medical Specialty
• Strong communication skills
• 5 years of established clinical experience
• Knowledge of the managed care industry including Medicare, Medicaid and/or Commercial products
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
  
  

Preferred Qualifications

• Medical/surgical utilization management review experience
• Experience in working with health care organizations, hospitals and/or healthcare providers
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and/or General Surgery specialty
  
  

Work at Home Guidance

To Ensure Home Or Hybrid Home/Office Associates’ Ability To Work Effectively, The Self-provided Internet Service Of Home Or Hybrid Home/Office Associates Must Meet The Following Criteria

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
  
  

This is a remote position reporting to Grievance and Appeals Director or MD Team Lead

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$241,300 - $332,000 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description Of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.