Medical Director--Claims Management
Remote US
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.
The Medical Director’s work includes 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, and possible participation in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
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.
Use your skills to make an impact
Required Qualifications
- MD or DO degree
- 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age).
- Board Certified in an approved ABMS Medical Specialty with continued certification throughout employment.
- A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), if required.
- No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
- Excellent verbal and written communication skills.
- Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services (such as inpatient rehabilitation)
Preferred Qualifications - Understands Medicare Inpatient Guidelines
- Knowledge …
This job isn't fresh anymore!
Search Fresh JobsJob Profile
Dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Illinois Montana Remote US South Dakota Work from a dedicated space Work from a dedicated space lacking ongoing interruptions Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Work from Home in the state of California, Illinois, Montana, or South Dakota
Benefits/PerksBonus Incentive Bonus incentive plan Caring community Competitive benefits Dental Health insurance Holidays Impactful work Life Insurance Medical Paid parental and caregiver leave Paid Time Off Parental and Caregiver Leave Personal holidays Remote position Remote work Time off Vision Vision Benefits Volunteer time Volunteer time off Work From Home
Tasks- Communicate decisions
- Communication
- Communication of decisions
- Compliance
- Determinations
- Documentation
- Overview of coding practices and clinical documentation
- Participation in care management
- Quality management
- Support regional market priorities
- Training
- Utilization Management
Analytic Analytics BI Business Care management Case Management Clinical Clinical Documentation Clinical Guidelines Clinical Review CMS policies Coding Coding practices Collaborative Communication Compensation Compliance Computer Conflict Resolution Discharge planning Documentation Emergency Medicine Family practice Geriatrics Healthcare Health Insurance Health Services HIPAA Hospitalist Inpatient rehabilitation Internal Medicine InterQual Judgement Leadership Managed Care Medicaid Medical background Medical Director Medicare Medicare Advantage National Guidelines Organizational Population health Prioritization Public health Quality Management Recruitment Regulatory Compliance Rehabilitation Social Determinants of Health Teams Training Utilization management Verbal and written communication Wellness Written communication
Experience5 years
EducationAdvanced degree Analytics Associates Business Communication DO Education Healthcare Health Services Management MBA M.D. MHA MPH Public health Rehabilitation
CertificationsABMS Medical Specialty Board Certification in ABMS Medical Specialty Board Certified in an approved ABMS Medical Specialty
TimezonesAmerica/Anchorage America/Chicago America/Denver America/Los_Angeles America/New_York Pacific/Honolulu UTC-10 UTC-5 UTC-6 UTC-7 UTC-8 UTC-9