Medical Director - Grievances and Appeals - Humana
Santa Fe, NM
About the Job
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 works on problems of diverse scope and complexity ranging from moderate to substantial.
The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Represents Humana at Administrative Law Judge hearings. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, Uses independent judgment requiring analysis of variable factors and determining the best course of action. Schedule is Monday-Friday with intermittent weekends OR a weekend shift with days off during the week
Use your skills to make an impact
Required Qualifications
+ 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
+ Excellent 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 utilization management experience,
+ working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
+ Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and General Surgery clinical specialists
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
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 yearThis 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.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
The Corporate Medical Director relies on medical background and reviews health claims and preservice appeals. The Corporate Medical Director works on problems of diverse scope and complexity ranging from moderate to substantial.
The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Represents Humana at Administrative Law Judge hearings. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, Uses independent judgment requiring analysis of variable factors and determining the best course of action. Schedule is Monday-Friday with intermittent weekends OR a weekend shift with days off during the week
Use your skills to make an impact
Required Qualifications
+ 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
+ Excellent 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 utilization management experience,
+ working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
+ Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and General Surgery clinical specialists
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
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 yearThis 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.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Source : Humana