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Medical Director - IP Claims Management
Location
United States
Posted
104 days ago
Salary
$223K - $313K / year
No structured requirement data.
Job Description
Medical Director - IP Claims Management
Humana
Become a part of our caring community and help us put health first 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. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS and state policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare, Medicare Advantage, and Medicaid 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. May occasionally participate in discussions with external physicians by phone to gather additional clinical information or discuss determinations which may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, dispute, 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 throughout all activities. Use your skills to make an impact Responsibilities The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS and state Medicaid requirements, Humana policies, clinical standards, and (in some cases) contracts. The ideal candidate supports and collaborates with other team members, other departments, and Humana colleagues. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. Supports the assigned work with respect to market-wide objectives and community relations as directed. 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). - Current and ongoing Board Certification an approved ABMS Medical Specialty - 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 - Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management. - Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. - Experience with national guidelines such as MCG® or InterQual - Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists - Advanced degree such as an MBA, MHA, MPH - Exposure to Public Health, Population Health, analytics, and use of business metrics. - Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health. - The curiosity to learn, the flexibility to adapt and the courage to innovate Additional Information Typically reports to a Lead Medical Director, depending on the line of business. The Medical Director conducts Utilization Management or clinical validation of the care received by members in an assigned line of business, member population, or condition type. May also engage in dispute, grievance, and appeals reviews. May participate on project teams or organizational committees. #physiciancareers Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $223,800 - $313,100 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 09-01-2026 About us Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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