Medical Director - Medicare Grievances and Appeals @ Humana
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Job Details
Overview
The Medical Director - Medicare Grievances and Appeals at Humana plays a key role in reviewing health claims and preservice appeals using clinical expertise. You will apply independent judgment on complex medical issues and represent Humana at Administrative Law Judge hearings.
Key Responsibilities
- Review and interpret Medicare claims and appeals
- Apply independent clinical judgment on diverse cases
- Represent Humana at legal hearings
- Support the medical director team on enterprise-wide business needs
Required Qualifications
MD or DO degree with a current, unrestricted license, board certification in an approved ABMS Medical Specialty (e.g., Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, Physical Medicine and Rehab, Anesthesiology or General Surgery), excellent written and communication skills, and a minimum of 5 years post-residency clinical experience. Familiarity with the managed care industry, including Medicare, Medicaid, and/or Commercial products, is essential.
Preferred Qualifications
Experience in medical utilization management and working with health insurance organizations, hospitals, and other healthcare providers.
Work Arrangement & Schedule
This is a remote position with a schedule of four 10-hour workdays per week (either Thursday-Sunday or Friday-Monday). Occasional travel to Humana offices for training or meetings may be required.
Compensation & Benefits
The base pay is estimated between $246,100 and $344,200 per year, plus eligibility for a bonus incentive plan. Benefits include medical, dental, vision, 401(k), paid time off, disability coverage, life insurance, and more.
About Humana
Humana is committed to putting health first for its teammates, customers, and communities by simplifying healthcare and delivering timely care via its insurance and healthcare services.
Key skills/competency
- Medicare
- Grievances
- Appeals
- Clinical Judgment
- Managed Care
- Utilization Management
- Medical Claims
- Regulatory Compliance
- Communication
- Remote Work
How to Get Hired at Humana
🎯 Tips for Getting Hired
- Customize your resume: Tailor it to highlight clinical experience.
- Research Humana: Understand their mission and values.
- Highlight managed care: Emphasize Medicare and claims expertise.
- Prepare for behavioral questions: Reflect on leadership and decision making.