Medical Director - Medicare Appeals
CVS HealthFull Time
Mid-level (3 to 4 years)
Candidates must possess an MD or DO degree with at least 5 years of direct clinical patient care experience post residency or fellowship, preferably including inpatient or Medicare-eligible population care. A current and ongoing Board Certification in an approved ABMS Medical Specialty and an unrestricted license in at least one jurisdiction are required, with willingness to obtain additional licenses. Candidates must not have current sanctions from Federal or State Governmental organizations and must pass credentialing requirements. Excellent verbal and written communication skills, along with demonstrated analytic and interpretation skills, are essential. Preferred qualifications include knowledge of the managed care industry, utilization management experience, familiarity with national guidelines like MCG or InterQual, hospital-based clinical practice experience, and exposure to public health, population health, analytics, and business metrics. Experience working with case managers on complex cases, including social determinants of health, is also preferred.
The Medical Director will actively use their medical background to determine if requested services, level of care, and site of service should be authorized, ensuring compliance with regulatory requirements, national clinical guidelines, CMS policies, and Humana policies. This role involves reviewing medical records, synthesizing complex clinical scenarios, and making expert decisions on requested services. The Medical Director will engage in regular discussions with external providers to gather clinical information and communicate determinations. They will provide medical interpretation and determinations for services rendered by other healthcare professionals, collaborating with team members, other departments, and Humana colleagues. After structured training, daily work will be performed with minimal direction, but with available support from team members, emphasizing consistency in thinking and authorship, and meeting compliance timelines.
Health insurance provider for seniors and military
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.