Medical Director--Claims Management

$199,400 - $274,400/Yr

Humana - Montpelier, VT

Full-time - Senior

Remote - Montpelier, VT

Insurance Carriers and Related Activities

About the position

The Medical Director in Claims Management at Humana is responsible for utilizing their medical expertise to assess and authorize requested services and levels of care for patients, primarily in inpatient settings. This role involves reviewing clinical scenarios, communicating decisions, and collaborating with external physicians to ensure compliance with Medicare and Medicare Advantage requirements. The Medical Director also engages in quality management and supports Humana's mission of promoting health and wellness in the community.

Responsibilities

• Review and authorize requested services and levels of care at the inpatient level.
• Conduct computer-based reviews of clinical scenarios and submitted clinical records.
• Communicate decisions to internal associates and participate in care management as needed.
• Engage with external physicians to gather clinical information and resolve conflicts.
• Support regional market priorities through collaboration with external physicians and community groups.
• Participate in grievance and appeals processes as required.

Requirements

• MD or DO degree
• 5+ years of direct clinical patient care experience post residency or fellowship, preferably in an inpatient environment or with Medicare populations.
• Board Certified in an approved ABMS Medical Specialty with continued certification throughout employment.
• Current and unrestricted medical license in at least one jurisdiction.
• No current sanctions from Federal or State Governmental organizations.
• Excellent verbal and written communication skills.
• Analytic and interpretation skills with experience in quality management, utilization management, or case management.

Nice-to-haves

• Understanding of Medicare Inpatient Guidelines
• Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid
• Utilization management experience in a medical management review organization
• Experience with national guidelines such as MCG® or InterQual
• Clinical specialization in Internal Medicine, Family Practice, Geriatrics, Hospitalist, or Emergency Medicine
• Advanced degree such as an MBA, MHA, or MPH
• Exposure to Public Health principles and Population Health analytics.

Benefits

• Medical, dental, and vision benefits
• 401(k) retirement savings plan
• Paid time off including company and personal holidays
• Volunteer time off
• Paid parental and caregiver leave
• Short-term and long-term disability
• Life insurance