Payment Integrity Program Development Manager
Devoted HealthSalary not specified
- Full Time
- Junior (1 to 2 years)
Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
HealthcareIndustries
Requirements
Candidates must hold an MD or DO degree, possess 5+ years of direct clinical patient care experience post-residency or fellowship, including experience in an inpatient environment or with Medicare-type populations, and be board-certified in an approved ABMS Medical Specialty. They must also hold a current and unrestricted license in at least one jurisdiction and be free from any current sanctions from governmental organizations.
Responsibilities
The Medical Director provides medical interpretation and determinations regarding service appropriateness, ensuring alignment with national guidelines, CMS requirements, Humana policies, and clinical standards. They review clinical records, prioritize daily work, communicate decisions, and potentially engage in peer-to-peer discussions. The role involves supporting team members, collaborating across departments, and meeting compliance timelines while supporting market-wide objectives and community relations. Additionally, the Medical Director may oversee coding practices, clinical documentation, dispute/grievance processes, and outpatient services.
Skills
Medical review
Clinical guidelines
CMS policies
Regulatory compliance
Clinical documentation
Peer-to-peer discussion
Coding practices
Dispute/grievance handling
Outpatient services
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.
Key Metrics
Louisville, KentuckyHeadquarters
1961Year Founded
IPOCompany Stage
Social Impact, HealthcareIndustries
10,001+Employees