Job Description: Corporate Medical Director

Position Overview

• Location Type: Remote
• Employment Type: Full Time
• Salary: Not specified

The Corporate Medical Director (CMD) plays a crucial role in reviewing health claims and preservice appeals, utilizing their medical expertise to ensure compliance with coverage policies and procedures. This role involves complex problem-solving, independent clinical judgment, and representing Humana at Administrative Law Judge hearings. The CMD provides medical interpretation and decisions regarding the appropriateness and medical necessity of services. The schedule is four 10-hour workdays per week, either Friday-Monday or Thursday-Sunday.

Requirements

• Education: MD or DO degree
• Licensure: Current and unrestricted license in at least one state, and willingness to obtain licenses as required for various states in the region of assignment.
• Board Certification: Board Certified in an approved ABMS Medical Specialty (Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, Physical Medicine and Rehab, Anesthesiology, or General Surgery)
• Experience: 5 years of established, post-residency clinical experience
• Knowledge: Knowledge of the managed care industry, including Medicare, Medicaid, and/or Commercial products.

Responsibilities

• Review health claims and preservice appeals.
• Provide medical interpretation and decisions regarding the appropriateness and medical necessity of services.
• Represent Humana at Administrative Law Judge hearings.
• Exercise independent clinical judgment and decision-making on complex issues.
• Assist in supporting the medical director team and leaders in meeting enterprise-wide business needs.
• Maintain compliance with coverage policies, procedures, and performance standards.

Application Instructions

• Not specified in the provided text.

Company Information

• Company: Humana
• Focus: Continuously improving consumer experiences.
• Work Arrangement: Remote (with potential for travel)
• Schedule: Four 10-hour workdays per week (Friday-Monday or Thursday-Sunday)
• Internet Requirements: Minimum download speed of 25 Mbps and upload speed of 10 Mbps. Satellite, cellular, and microwave connections may be considered with leadership approval. Associates in California, Illinois, Montana, and South Dakota will receive a bi-weekly payment for internet expenses. Humana will provide telephone equipment.

Preferred Qualifications

• Medical utilization management experience
• Experience working with health insurance organizations, hospitals, and other healthcare providers.
• Patient interaction experience.