[Remote] Director, G&A Internal Review Team (Resolution Team) at Humana

Kentucky, United States

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Not SpecifiedCompensation

Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess a Master's degree or higher (e.g., JD, PhD) and have over 10 years of leadership experience managing large, cross-functional teams in high-stress environments. A minimum of 4 years of experience with the Medicare Appeals process, CMS Independent Review Entity, and CMS/State requirements, including their impact on Stars ratings, is required. Comprehensive understanding of Medicare regulations and Stars measures, along with financial savviness, is also necessary.

Responsibilities

The Director will provide strategic leadership to operational teams, ensuring compliance requirements are met and driving performance for Medicare Star measures. They will simplify and improve processes, drive operational efficiencies, and enhance IRE Stars performance by focusing on timeliness and consistency. This role involves collaborating with upstream business partners to identify improvement opportunities and leading initiatives for better performance. The Director will also cultivate a motivated and adaptable team culture, assess and develop talent, and ensure organizational performance during transformation. Key responsibilities include implementing quality control measures, preparing for CMS program audits, developing and implementing policies for grievances and appeals, and recommending process improvements to enhance member and provider satisfaction.

Skills

Medicare regulations

Grievances and Appeals management

Operational excellence

Process improvement

Team leadership

Performance management

Regulatory compliance

Customer experience

Strategic leadership

Audit readiness

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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