Director, Medical Economics/Medical Expense Actuary
Devoted HealthSalary not specified
- Full Time
- Senior (5 to 8 years)
Humana
Corporate Medical Director - Medicare Grievances and Appeals (32-Hours)
Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
HealthcareIndustries
Requirements
Candidates must hold an MD or DO degree, be board certified in an approved ABMS Medical Specialty such as Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, or Physical Medicine and Rehabilitation, and Anesthesiology or General Surgery trained. They should possess at least five years of established, post-residency clinical experience, excellent written and communication skills, and knowledge of the managed care industry including Medicare, Medicaid, and/or Commercial products. A current and unrestricted license in at least one state, with willingness to obtain licenses as required for various states, is also required.
Responsibilities
The Corporate Medical Director will review health claims and preservice appeals utilizing their medical background, provide medical interpretation and decisions regarding the appropriateness and medical necessity of services, represent Humana at Administrative Law Judge hearings, exercise independent clinical judgment on complex issues, assist in supporting the medical director team and leaders, and contribute to meeting enterprise-wide business needs. They will also monitor and interpret changes in employment legislation across North America and develop HR policies to ensure compliance.
Skills
Medical interpretation
Claims review
Appeals process
Clinical judgment
Communication skills
Knowledge of Medicare, Medicaid, Commercial insurance
Humana
Health insurance provider for seniors and military
About Humana
Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.
Key Metrics
Louisville, KentuckyHeadquarters
1961Year Founded
IPOCompany Stage
Social Impact, HealthcareIndustries
10,001+Employees