[Remote] Medical Director - Claims Management at Humana

San Antonio, Texas, United States

Apply Now

Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, preferably including experience with Medicare populations
Current and ongoing Board Certification in an approved ABMS Medical Specialty
Current and unrestricted license in at least one jurisdiction
No current sanction from Federal or State Governmental organizations
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills, with experience in quality management, utilization management, case management, discharge planning, or home health/post-acute services

Responsibilities

Actively use medical background, experience, and judgement to make determinations on service authorization
Computer-based review of moderately complex to complex clinical scenarios
Review of all submitted clinical records
Prioritization of daily work
Communication of decisions to internal associates
Possible participation in care management
Occasionally participate in discussions with external physicians to gather clinical information or discuss determinations
May have an overview of coding practices and clinical documentation
May participate in dispute, grievance, and appeals processes
May have an overview of outpatient services and equipment
May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities
Support Humana values throughout all activities
Provide medical interpretation and determinations whether services are in agreement with guidelines, requirements, policies, and standards
Support and collaborate with team members and other departments
Exercise independence in meeting departmental expectations and meeting compliance timelines
Support assigned work with respect to market-wide objectives and community relations

Skills

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