Corporate Medical Director - Medicare Grievances and Appeals (32-Hours)

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, Managed CareIndustries

Requirements

Candidates must possess an MD or DO degree, hold a current and unrestricted medical license in at least one state (with willingness to obtain others as needed), and be Board Certified in an approved ABMS Medical Specialty such as Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, Physical Medicine and Rehab, Anesthesiology, or General Surgery. A minimum of 5 years of post-residency clinical experience and knowledge of the managed care industry, including Medicare, Medicaid, and/or Commercial products, are also required. Excellent written and communication skills are essential.

Responsibilities

The Corporate Medical Director will review health claims and preservice appeals, providing medical interpretation and decisions on the appropriateness and medical necessity of services in compliance with coverage policies. This role involves representing Humana at Administrative Law Judge hearings, exercising independent clinical judgment on complex issues, and working with minimal supervision. The Director will also assist the medical director team and leaders in meeting enterprise-wide business needs, and after training, will work four 8-hour days per week on a rotating schedule (Friday-Monday or Thursday-Sunday).

Skills

Medical claims review

Preservice appeals review

Medical necessity determination

Clinical judgment

Managed care

Medicare

Medicaid

Commercial insurance

Utilization management

Written communication

Verbal communication

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.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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