Grievances and Appeals Medical Director

Description

The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing appeals for Medicare Part C Line of Business. The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. Candidates may live anywhere in the US but MUST work East Coast hours. This position will work four ten hour shifts a week and will include coverage of every Saturday and Sunday.

Responsibilities

The Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. All work occurs with 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 sources of expertise.  Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work. After completion of mentored training, daily work is performed with minimal direction. The Medical Director works in a structured environment with expectations for consistency in thinking, authorship, meeting departmental expectations, and compliance timelines.

               

Required Qualifications

• MD or DO degree
• Current and ongoing board certification in an approved ABMS Medical Specialty
• A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment
• 5 years of direct clinical patient care experience post residency or fellowship
• No current sanction from Federal or State Governmental organizations
• The ability to pass credentialing requirements
• Excellent verbal and written communication skills with analytic and interpretative skills
• Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual

Preferred Qualifications

• Experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
• Internal Medicine, Family Practice, Geriatrics, or hospital based clinical specialists
• Ability to function in a dynamic fast paced environment
• Commitment to a culture of innovation
• Passionate about contributing to an organization’s focus on consistency in outcomes, consumer experiences and a highly engaged team culture

The Medical Director conducts clinical case reviews of the appeals received by members of the Medicare population and reports to the Lead Medical Director.

Other duties:

• Identify medical management operational improvements, including those within the medical director area
• Participate in weekend work rotation
• Develop collaborative relationships with Team and key partners within the Medicare Line of Business.
• Support G&A MD Team engagement, operational, and other meetings
• Other activities as assigned by the Lead Medical Director

Additional Information

Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. Some medical directors may join a centralized team for several months after training, until positions become available for specific markets.  May participate on project teams or organizational committees.

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

This is a remote position
#LI-Remote

Scheduled Weekly Hours

40