Grievances and Appeals Medical Director - Weekends Required

Profile

Description

The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing appeals for Medicare Part C Line of Business. The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. Candidates may live anywhere in the US but must be available to work East Coast hours. This position is for four, ten-hour workdays, which must include Saturday and Sunday.

Responsibilities

The 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. All work occurs with a context of regulatory compliance, and work is assisted by diverse resources which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work. After completion of mentored training, daily work is performed with minimal direction. The Medical Director works in a structured environment with expectations for consistency in thinking, authorship, meeting departmental expectations, and compliance timelines.

This position is for four, ten-hour workdays, which must include Saturday and Sunday.

Required Qualifications


MD or DO degree.
Current and ongoing board certification in an approved ABMS Medical Specialty
A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment.
5 years of direct clinical patient care experience post residency or fellowship
No current sanction from Federal or State Governmental organizations
The ability to pass credentialing requirements.
Excellent verbal and written communication skills with analytic and interpretative skills
Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual


Preferred Qualifications


Experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
Internal Medicine, Family Practice, Geriatrics, or hospital based clinical specialists.
Ability to function in a dynamic fast paced environment.
Commitment to a culture of innovation
Passionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team culture.


The Medical Director conducts clinical case reviews of the appeals received by members of the Medicare population and reports to the Lead Medical Director.

Other duties:


Identify medical management operational improvements, including those within the medical director area.
Must participate in weekend work rotation
Develop collaborative relationships with Team and key partners within the Medicare Line of Business.
Support G&A MD Team engagement, operational, and other meetings
Other activities as assigned by the Lead Medical Director


Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Scheduled Weekly Hours

40

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 ****

Company info

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