MEDICAL DIRECTOR-CLAIMS MANAGEMENT
Company: Humana
Location: Providence
Posted on: October 19, 2024
Job Description:
Humana Medical Director--Claims Management Providence, Rhode
Island Apply NowBecome a part of our caring community and help us
put health first
Remember to check your CV before applying Also, ensure you read
through all the requirements related to this role.
The Medical Director actively uses their medical background,
experience, and judgement to make determinations whether requested
services, requested level of care, and/or requested site of service
should be authorized at the Inpatient level. All work occurs within
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 reference sources. Medical
Directors will learn Medicare and Medicare Advantage requirements
and will understand how to operationalize this knowledge in their
daily work.The Medical Director's work includes computer-based
review of moderately complex to complex clinical scenarios, review
of all submitted clinical records, prioritization of daily work,
communication of decisions to internal associates, and possible
participation in care management. The clinical scenarios
predominantly arise from inpatient or post-acute care environments.
Has discussions with external physicians by phone to gather
additional clinical information or discuss determinations
regularly, and in some instances these may require conflict
resolution skills. Some roles include an overview of coding
practices and clinical documentation, grievance and appeals
processes, and outpatient services and equipment, within their
scope.The Medical Director may speak with contracted external
physicians, physician groups, facilities, or community groups to
support regional market priorities, which may include an
understanding of Humana processes, as well as a focus on
collaborative business relationships, value based care, population
health, or disease or care management. Medical Directors support
Humana values, and Humana's Bold Goal mission, throughout all
activities.Use your skills to make an impactRequired
Qualifications
- MD or DO degree
- 5+ years of direct clinical patient care experience post
residency or fellowship, which preferably includes some experience
in an inpatient environment and/or related to care of a Medicare
type population (disabled or > 65 years of age).
- Board Certified in an approved ABMS Medical Specialty with
continued certification throughout employment.
- A current and unrestricted license in at least one jurisdiction
and willing to obtain additional license(s), if required.
- No current sanction from Federal or State Governmental
organizations, and able to pass credentialing requirements.
- Excellent verbal and written communication skills.
- Evidence of analytic and interpretation skills, with prior
experience participating in teams focusing on quality management,
utilization management, case management, discharge planning and/or
home health or post-acute services (such as inpatient
rehabilitation).Preferred Qualifications
- Knowledge of the managed care industry including Medicare
Advantage, Managed Medicaid and/or Commercial products, or other
Medical management organizations, hospitals/ Integrated Delivery
Systems, health insurance, other healthcare providers, clinical
group practice management.
- Utilization management experience in a medical management
review organization, such as Medicare Advantage, managed Medicaid,
or Commercial health insurance.
- Experience with national guidelines such as MCG or
InterQual.
- Internal Medicine, Family Practice, Geriatrics, Hospitalist,
Emergency Medicine clinical specialization.
- Advanced degree such as an MBA, MHA, or MPH.
- Exposure to Public Health principles, Population Health,
analytics, and use of business metrics.
- Experience working with Case managers or Care managers on
complex case management, including familiarity with social
determinants of health.The curiosity to learn, the flexibility to
adapt and the courage to innovate.Additional InformationTypically
reports to a Director of Health Services, Lead, or Corporate
Medical Director, depending on size of region or line of business.
The Medical Director conducts Utilization Management of the care
received by members in an assigned market, member population, or
condition type. May also engage in grievance and appeals reviews.
Some medical directors may join a centralized team for several
months after training, until positions become available for
specific markets. May participate on project teams or
organizational committees.Work at Home GuidanceTo 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
#LI-RemoteScheduled Weekly Hours40Pay RangeThe 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. $199,400 -
$274,400 per year. This job is eligible for a bonus incentive plan.
This incentive opportunity is based upon company and/or individual
performance.Description of BenefitsHumana, 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 usHumana 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 EmployerIt 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
accessibility resources.
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Keywords: Humana, Nantucket , MEDICAL DIRECTOR-CLAIMS MANAGEMENT, Healthcare , Providence, Massachusetts
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