Medical Director - Medicare Grievances and Appeals - Weekend

Humana; United States; Remote; USD 246,000 - 345,000; Full time

Job summary

Join a forward-thinking organization dedicated to health and well-being as a Corporate Medical Director. In this pivotal role, you will leverage your medical expertise to review health claims and make critical decisions regarding service appropriateness. This position offers a unique opportunity to work in a supportive environment, where your contributions directly impact the quality of healthcare delivery. With a flexible schedule of four 10-hour workdays, you will enjoy a balance between professional responsibilities and personal time. If you are passionate about making a difference and improving consumer experiences, this role is perfect for you.

Benefits

Medical, dental, and vision benefits

401(k) retirement savings plan

Paid time off

Short-term and long-term disability

Life insurance

Qualifications

• Must hold an MD or DO degree with board certification.
• 5+ years of clinical experience required.

Responsibilities

• Review health claims and preservice appeals for medical necessity.
• Provide medical interpretation and decisions in compliance with policies.

Skills

MD or DO degree

Board Certified in an approved ABMS Medical Specialty

Excellent written and communication skills

5 years of established, post-residency clinical experience

Knowledge of the managed care industry

Passion for improving consumer experiences

Education

Medical Degree (MD or DO)

Job description

Become a part of our caring community and help us put health first
The Corporate Medical Director (CMD) relies on medical background to review health claims and preservice appeals. The Corporate Medical Director works on problems of diverse scope and complexity ranging from moderate to substantial.

The Corporate Medical Director provides medical interpretation and decisions regarding the appropriateness and medical necessity of services provided by other healthcare professionals in compliance with coverage policies, procedures, and performance standards. CMD represents Humana at Administrative Law Judge hearings; exercises independent clinical judgment and decision making on complex issues regarding job duties and related tasks; works under minimal supervision; and assists in supporting the medical director team and leaders in meeting enterprise-wide business needs. After an initial training period, schedule is four 10-hour workdays per week, Thursday-Sunday, or Friday-Monday .

Use your skills to make an impact

Required Qualifications

• MD or DO degree
• A current and unrestricted license in at least one state and willing to obtain license, as required, for various states in region of assignment
• Board Certified in an approved ABMS Medical Specialty
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, Physical Medicine and Rehab, Anesthesiology or General Surgery trained
• Excellent written and communication skills
• 5 years of established, post-residency clinical experience
• Knowledge of the managed care industry including Medicare, Medicaid and/or Commercial products
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Medical utilization management experience
• Working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.

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.

Scheduled weekly hours :

40 hours (full-time): four 10-hour workdays per week, either Friday-Monday or Thursday-Sunday schedule.

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.$246,100 - $344,200 per yearThis 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: 07-31-2025
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.