Medical Director - Medicare Appeals
CVS HealthFull Time
Mid-level (3 to 4 years)
Candidates must have 3 or more years of Medicare and/or Medicaid claims processing or auditing experience, along with over 1 year of leadership, coaching, or team leadership experience. A minimum of 1 year of experience working in CAS and CI, along with 1 year of X-12 data knowledge is preferred. Prior demonstrated experience with project management and working knowledge of SQL writing, creating, and/or running queries (ORACLE, Microsoft SQL Server) are also preferred qualifications. Candidates should possess comprehensive knowledge of all Microsoft Office applications, including Word, PowerPoint, Outlook, and intermediate Excel skills. A Bachelor's degree in Business, Finance, Operations, or other related fields is preferred. The role requires the ability to manage multiple tasks and deadlines with attention to detail, excellent communication skills, and the ability to work independently and manage multiple priorities simultaneously. For remote work, a high-speed DSL or cable modem with a minimum speed of 25mbps download and 10mbps upload is required, and satellite or wireless internet service is not allowed.
The Senior Encounter Data Management Professional develops business processes to ensure successful submission and reconciliation of encounter submissions to Medicaid/Medicare, ensuring compliance standards are met or exceeded through data analysis. They develop tools to enhance encounter acceptance rates and identify long-term improvements for encounter submission and error correction processes. This role involves leading a team of 2-5 associates, serving as a subject matter expert for error corrections teams, and facilitating collaborative meetings to provide status updates. The professional presents summaries of inventory, successes, and concerns to internal business partners, serves as a point of contact for special projects, and identifies opportunities for process improvements. They also provide ongoing support and training to direct reports and production associates, and make decisions on complex issues regarding technical approach and error correction resolution, influencing departmental strategy.
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.