[Remote] Medical Director - Claims Management at Humana

San Antonio, Texas, United States

Apply Now

Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
Current and ongoing Board Certification in an approved ABMS Medical Specialty
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

Responsibilities

Actively use medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized, within a context of regulatory compliance assisted by diverse resources (e.g., national clinical guidelines, CMS and state policies, clinical reference materials, internal teaching conferences)
Learn Medicare, Medicare Advantage, and Medicaid requirements and operationalize this knowledge in daily work
Perform computer-based review of moderately complex to complex clinical scenarios and review of all submitted clinical records
Prioritize daily work and communicate decisions to internal associates
Possibly participate in care management
Occasionally participate in discussions with external physicians by phone to gather additional clinical information or discuss determinations requiring conflict resolution skills
In some roles, provide overview of coding practices and clinical documentation, dispute, grievance, and appeals processes, and outpatient services and equipment, within scope
Speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities (e.g., understanding Humana processes, collaborative business relationships, value-based care, population health, disease or care management)
Support Humana values throughout all activities
Provide medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS and state Medicaid requirements, Humana policies, clinical standards, and (in some cases) contracts
Support and collaborate with other team members, other departments, and Humana colleagues
After mentored training, perform daily work with minimal direction in a structured environment with expectations for consistency in thinking and authorship
Exercise independence in meeting departmental expectations and meet compliance timelines
Support assigned work with respect to market-wide objectives and community relations as directed

Skills

Medicare

Medicaid

Medicare Advantage

CMS

Utilization Review

Claims Adjudication

Clinical Guidelines

Coding

Clinical Documentation

Appeals Processing

Care Management

Value-Based Care

Population Health

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.

Land your dream remote job 3x faster with AI

Try Jobo Free