Medical Director - Medicare Grievances and Appeals - Weekend
HumanaSalary not specified
Full Time
Senior (5 to 8 years)
Not SpecifiedCompensation
Mid-level (3 to 4 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries
Requirements
Candidates must possess a Medical License (MD or DO) and an active state medical license without encumbrances. A minimum of two years of experience in a Health Care Delivery System, such as clinical practice or the health care industry, is required. Preferred qualifications include experience in Medical Management, specifically with Medicare Complaints, Grievances, and Appeals, as well as Health Plan experience.
Responsibilities
The Medical Director will oversee daily operations for Part C appeals, including both provider and member/nonparticipating provider cases. They will provide direct support and supervision to appeal nurses, participating in the Second Look Review (SLR) process. Responsibilities also include providing after-hours and weekend coverage on a rotational basis, monitoring and tracking IRE, supporting Utilization Management Strategy, and collaborating with Medicare Quality and Compliance. The role involves developing expertise in Medicare policy, educating staff on Medicare policy and appeals, and participating in initiatives to enhance appeals team efficiency and clinical consistency.
Skills
Medicare Appeals
Part C appeals
Provider appeals
Member appeals
Second Look Review (SLR)
IRE monitoring
Utilization Management Strategy
Medicare policy
Clinical practice
Health care industry
CVS Health
Comprehensive pharmacy and healthcare services
About CVS Health
CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.
Woonsocket, Rhode IslandHeadquarters
1963Year Founded
DEBTCompany Stage
Healthcare, Consumer GoodsIndustries
10,001+Employees