Medical Director, Medicare Grievances

📋 Description

• • As a Medical Director, Medicare Grievances at Humana Inc., you will play a pivotal role in ensuring the integrity and quality of healthcare services provided to our Medicare members. This remote, nationwide position requires a physician with a strong medical background and a deep understanding of the managed care industry, particularly Medicare regulations and processes.
• • Your primary responsibility will be to provide expert medical interpretation and make critical decisions regarding the appropriateness of services rendered by other healthcare professionals. This involves meticulously reviewing health claims and ensuring compliance with Humana's established review policies, procedures, and performance standards.
• • You will be entrusted with independent decision-making on complex issues, necessitating a thorough analysis of variable factors to determine the optimal course of action. This role demands a high level of critical thinking and problem-solving skills to navigate the intricacies of healthcare delivery and member grievances.
• • The scope of your work will encompass problems of diverse and substantial complexity, requiring you to leverage your clinical expertise and knowledge of managed care to uphold the highest standards of patient care and regulatory adherence.
• • You will be a key contributor to quality management initiatives, working with teams focused on utilization management, discharge planning, and home health or rehabilitation services. Your insights will be crucial in optimizing care pathways and ensuring efficient, effective patient outcomes.
• • This role offers a unique opportunity to apply your medical knowledge in a strategic capacity, influencing healthcare delivery and contributing to an organization dedicated to improving consumer experiences and putting health first.
• • You will engage with health insurance organizations, hospitals, and other healthcare providers, fostering collaborative relationships to ensure seamless patient care and effective grievance resolution.
• • The position requires a commitment to continuous learning and staying abreast of evolving healthcare policies, regulations, and best practices within the Medicare landscape.
• • Your analytical and interpretation skills will be paramount in assessing medical necessity, evaluating treatment plans, and making sound judgments that align with both clinical best practices and organizational objectives.
• • You will contribute to the development and refinement of medical policies and procedures, ensuring they are current, effective, and supportive of Humana's mission.
• • The role involves a balance of independent work and collaboration, requiring you to effectively communicate medical opinions and rationale to internal teams, external providers, and potentially regulatory bodies.
• • You will be instrumental in identifying trends and patterns in grievances, providing valuable feedback to improve healthcare delivery and member satisfaction.
• • The schedule is Monday-Friday, with intermittent weekends. One weekend per month is generally required, with compensation days provided to ensure work-life balance.
• • This is a fully remote position, allowing you to work from your home office nationwide, with the understanding that occasional travel to Humana's offices for training or meetings may be required.
• • You will be provided with the necessary telephone equipment to meet position requirements, and your self-provided internet service must meet minimum speed recommendations (25 Mbps download, 10 Mbps upload) for optimal performance.
• • A dedicated, interruption-free workspace is essential to protect member Protected Health Information (PHI) and ensure HIPAA compliance.
• • This role is ideal for a physician passionate about making a significant impact on the health and well-being of Medicare beneficiaries, contributing to a leading healthcare organization committed to putting health first.
• • You will be part of a caring community that values innovation, collaboration, and a dedication to improving healthcare outcomes for millions of individuals.
• • The opportunity to work with a diverse range of clinical specialists, including Internal Medicine, Family Practice, Geriatrics, and Hospitalist specialists, will enrich your professional experience and broaden your perspective.
• • Your expertise will directly contribute to Humana's mission of making it easier for people to achieve their best health, delivering the care and service they need, when they need it.
• • This position offers a competitive salary range and eligibility for a bonus incentive plan based on company and/or individual performance, reflecting the significant value and responsibility of this role.