Medical Director - Medicare Appeals
CVS HealthFull Time
Mid-level (3 to 4 years)
Candidates must possess an MD or DO degree and have at least 5 years of direct clinical patient care experience post residency or fellowship, preferably including inpatient or acute inpatient rehabilitation experience. Board certification in an approved ABMS Medical Specialty is required, along with a current, unrestricted medical license in at least one jurisdiction and willingness to obtain additional licenses as needed. Applicants must not have current sanctions from federal or state governmental organizations and must be able to pass credentialing requirements. Excellent verbal and written communication skills, along with demonstrated analytic and interpretation skills, are essential. Preferred qualifications include knowledge of the managed care industry, utilization management experience, a background in Physical Medicine and Rehabilitation, Internal Medicine, Family Practice, Geriatrics, or Hospitalist medicine, and an advanced degree such as an MBA, MHA, or MPH.
The Medical Director will use their medical background and judgment to determine if requested services, level of care, and site of service are authorized, adhering to regulatory compliance, national clinical guidelines, CMS policies, and internal standards. This role involves computer-based review of clinical scenarios, primarily from post-acute care environments, reviewing submitted clinical records, prioritizing daily work, and communicating decisions to internal associates. Responsibilities include discussing clinical scenarios with external physicians via phone to gather information or discuss determinations, potentially involving conflict resolution. The Medical Director will provide medical interpretation and determinations on acute inpatient rehabilitation authorization requests, supporting and collaborating with team members and other departments. Daily work will be performed with minimal direction after structured training, with an expectation for consistency in thinking and authorship, and independence in meeting enterprise expectations and compliance timelines. The role may also involve grievance and appeals reviews.
Health insurance provider for seniors and military
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.