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), Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Health Insurance, HealthcareIndustries
Requirements
Candidates must possess an active state medical license (MD or DO) without encumbrances and be board-certified in an ABMS or AOA recognized specialty. 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 of Medicare complaints, grievances, and appeals, as well as health plan experience.
Responsibilities
The Medical Director will oversee daily operations for Medicare Part C appeals, including provider and non-participating provider cases. They will provide direct support to appeal nurses and Medicare Part D pharmacists, and participate in the Second Look Review (SLR) process and Quality Review. Responsibilities also include providing after-hours and weekend coverage for appeals, monitoring IRE, supporting Utilization Management Strategy, and developing expertise in Medicare policy. The role involves educating appeal nurses and Utilization Management staff on Medicare policy and appeals, and participating in initiatives to enhance the efficiency and consistency of the appeals team.
Skills
Medicare Appeals
Part C Appeals
Part D Appeals
Quality Review
Utilization Management
Medicare Policy
Medical License (MD)
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