Medical Director, Claims

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess medical requests to determine authorization for services, level of care, and service site at both Initial and Appeals/Disputes stages.

• Perform computer-based evaluations of moderately complex to complex clinical situations.

• Review clinical records submitted and prioritize daily tasks.

• Communicate decisions to internal team members.

• Engage in care management as necessary.

• Discuss conclusions and resolve any conflicts when appropriate.

• Evaluate coding practices, clinical documentation, grievance and appeals processes, outpatient services, and equipment within the defined scope.

• Interact with physicians, nurses, and internal collaborative teams.

• Offer medical interpretations and decisions in alignment with national guidelines, CMS requirements, Humana policies, clinical standards, and applicable contracts.

• Conduct Utilization Management for members within a designated market, member population, or specific condition type.

• Contribute to the review of disputes and appeals.

• Participate in project teams or organizational committees.

• Report directly to the Lead Medical Director.

⛳️ Requirements

• MD or DO degree.

• Over 5 years of direct clinical patient care experience following residency or fellowship, including both inpatient and outpatient exposure.

• Experience providing care to a Medicare-type population, such as individuals with disabilities or those over 65 years old.

• Active and ongoing board certification in an approved ABMS or AOA medical specialty.

• Current and unrestricted medical license in at least one jurisdiction.

• Willingness to acquire additional medical licenses.

• No current sanctions from federal or state governmental bodies.

• Capability to meet credentialing requirements.

• Demonstrated analytical and interpretive skills.

• Previous experience in quality management, utilization management, case management, discharge planning, and home health or post-acute services, including inpatient rehabilitation.

• Familiarity with the managed care landscape, including Medicare Advantage, Managed Medicaid, Commercial products, medical management organizations, hospitals/integrated delivery systems, health insurance, healthcare providers, and clinical group practice management.

• Experience in utilization management within a medical management review organization.

• Knowledge of national guidelines such as MCG® or InterQual.

• Clinical specialty background in Internal Medicine, Family Practice, Geriatrics, Hospitalist, or Emergency Medicine.

• Preferred: multiple medical licenses.

• Preferred: exposure to Public Health, Population Health, analytics, and business metrics.

• Preferred: experience with medical reviews related to Medicare Advantage and Medicaid Claims.

• Preferred: experience collaborating with Case Managers or Care Managers on complex case management, including an understanding of social determinants of health.

• Minimum home internet speed of 25 Mbps download and 10 Mbps upload.

• Ability to work from a designated space without ongoing interruptions to safeguard member PHI/HIPAA information.

🏝️ Benefits

• Bonus incentive plan based on company and/or individual performance.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays.

• Personal holidays.

• Paid parental leave.

• Paid caregiver leave.

• Short-term disability.

• Long-term disability.

• Life insurance.

• Dedicated work-from-home setup.

• Remote work arrangement.

• Occasional travel to Humana's offices for training or meetings.