Medical Director for Claims Management

1 week ago


Boise, Idaho, United States Humana Full time
Medical Director for Claims Management

Become a part of our caring community and help us put health first. The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized at the Inpatient level. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.

Key Responsibilities
  • Computer-based review of moderately complex to complex clinical scenarios
  • Review of all submitted clinical records
  • Prioritization of daily work
  • Communication of decisions to internal associates
  • Possible participation in care management

The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value based care, population health, or disease or care management. Medical Directors support Humana values, and Humana's Bold Goal mission, throughout all activities.

Requirements
  • MD or DO degree
  • 5+ years of direct clinical patient care experience post residency or fellowship
  • Board Certified in an approved ABMS Medical Specialty
  • A current and unrestricted license in at least one jurisdiction
  • Excellent verbal and written communication skills

This is a remote position. The compensation range is $199,400 - $274,400 per year. This job is eligible for a bonus incentive plan. Humana offers competitive benefits that support whole-person well-being, including medical, dental and vision benefits, 401(k) retirement savings plan, time off, short-term and long-term disability, life insurance, and many other opportunities.


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