[Remote] Medical Director - Medicare Grievances and Appeals Corporate at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

MD or DO degree
Current and unrestricted license in at least one jurisdiction
Willingness to obtain license for various states in the region of assignment
Board Certified in an approved ABMS Medical Specialty
5 years of established clinical experience
Excellent communication skills
Knowledge of the managed care industry, including Medicare, Medicaid, and/or Commercial products
Medical utilization management experience
Working with health insurance organizations, hospitals, and other healthcare providers
Patient interaction experience
Internal Medicine, Family Practice, Geriatrics, Hospitalist, Anesthesiology, Physical Medicine and Rehabilitation, Emergency Medicine, and General Surgery clinical specialists
Ability to work independently and make independent judgments
Ability to work with minimal supervision
Use of internet service for work purposes
Ability to meet the requirements for remote work, including:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps
Wireless, wired cable, or DSL connection
Satellite, cellular, and microwave connections may be used with approval from leadership
Bi-weekly payment for internet expense for associates who live and work from Home in the states of California, Illinois, Montana, or South Dakota
Telephone equipment provided for associates who live and work from Home in the states of California, Illinois, Montana, or South Dakota
Dedicated space for work without ongoing interruptions
Protection of member PHI/HIPAA information
Occasional travel to Humana's offices for training or meetings

Responsibilities

Review health claims and preservice appeals
Provide medical interpretation and decisions about the appropriateness of services
Represent Humana at Administrative Law Judge hearings
Exercise independent judgment and decision making on complex issues
Analyze variable factors and determine the best course of action
Schedule appointments and manage patient interactions
Work with healthcare providers and insurance organizations
Develop and implement medical policies and procedures
Collaborate with other healthcare professionals
Provide medical guidance and support to associates
Participate in training and professional development opportunities
Meet with associates to discuss their work and provide feedback
Participate in quality improvement initiatives
Contribute to the development of the Corporate Medical Director role
Represent Humana in a professional and respectful manner
Communicate effectively with associates, leadership, and other stakeholders
Maintain accurate and up-to-date records and documentation
Participate in performance reviews and evaluations
Adhere to Humana's policies and procedures
Participate in bonus incentive plan opportunities

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.

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