Medical Director Grievances & Appeals

at Humana in Boise, Idaho, United States

Become a part of our caring community

The Corporate Medical Director relies on medical background and reviews health claims. You will work on problems of diverse scope and complexity ranging from moderate to substantial.

The Corporate 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. You exercise independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action.

Schedule is Monday-Friday with intermittent weekends

Responsibilities

+ Provide clinical interpretation and determinations on the medical appropriateness of services delivered by healthcare professionals, including the application of evidence-based guidelines.

+ Make independent, timely, and defensible medical decisions on complex appeal cases, exercising professional judgment with minimal supervision.

+ Collaborate with cross-functional teams-including legal, compliance, and clinical operations-to address and resolve grievances and appeals.

+ Participate in quality improvement initiatives, identifying trends in grievances and appeals and recommending process improvements.

+ Serve as a clinical resource for grievance and appeals staff, providing guidance and education as needed.

+ Maintain current knowledge of Medicare regulations, managed care requirements, and industry best practices relevant to appeals and grievances.

+ Support Humanas commitment to continuous improvement in consumer experience, ensuring fair, consistent, and customer-focused outcomes.

+ Participate in internal and external audits as required and respond to regulatory inquiries as needed.

+ Adhere to all confidentiality and HIPAA requirements in handling protected health information ( PHI ).

+ Perform additional duties as assigned, including intermittent weekend work and holiday as required by the business.

Use your skills to make an impact

Required Qualifications

+ MD or DO degree completed at an accredited university in the USA

+ A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment

+ Board Certified in an approved ABMS / ABOA Medical Specialty

+ 5 years o