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Medical Services Lead
1 week ago
Welcome to Humana, where we prioritize health and wellness for our community.
We seek an experienced healthcare leader who can leverage their medical expertise to drive strategic decisions and shape our organization's future. This role involves reviewing health claims, making informed determinations about services, and working closely with external stakeholders to advance our mission.
As a key member of our team, you will be responsible for analyzing complex clinical scenarios, communicating with internal associates, and participating in care management initiatives. You will also engage in discussions with external physicians to gather additional information or discuss determinations. In some cases, conflict resolution skills may be required. Additionally, you may be involved in coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment within your scope.
Join our community of healthcare professionals who share your passion for putting health first.
Main Responsibilities- Make informed decisions about services provided by other healthcare professionals based on medical expertise and evidence-based guidelines.
- Build and maintain strong relationships with internal teams, departments, and external stakeholders to drive collaboration and shared success.
- Exercise leadership and judgment while adhering to regulatory requirements and compliance timelines.