Medical Director – Payment Integrity

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

📋 Description

• The Medical Director leverages their medical expertise, experience, and judgment to assess whether requested services, levels of care, and/or sites of service should be approved at the Inpatient level.

• Provides medical evaluations and decisions regarding whether services rendered by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and, in certain instances, contracts.

• Collaborates and supports fellow team members, other departments, Humana colleagues, and the Lead Medical Director.

• Conducts post-service reviews of inpatient care to ensure accurate billing of clinically valid diagnoses and services provided.

• Participates in dispute resolutions and reviews of grievances and appeals.

• Engages in project teams or organizational committees.

⛳️ Requirements

• MD or DO degree

• Minimum of 5 years of direct clinical patient care experience following residency or fellowship, ideally including experience in an inpatient setting and/or relating to the care of a Medicare population (disabled or over 65 years old).

• Current and active Board Certification in an approved ABMS Medical Specialty

• A valid and unrestricted medical license in at least one jurisdiction, with a willingness to obtain additional licenses if necessary.

• No active sanctions from Federal or State Government entities, and the ability to meet credentialing standards.

• Exceptional verbal and written communication abilities.

• Demonstrated analytical and interpretative skills, with previous experience in teams focused on quality management, utilization management, case management, discharge planning, and/or home health or post-acute services such as inpatient rehabilitation.

🏝️ Benefits

• Medical, dental, and vision benefits

• 401(k) retirement savings plan

• Time off (including paid time off, company and personal holidays, paid parental leave, and caregiver leave)

• Short-term and long-term disability coverage

• Life insurance and numerous additional opportunities