Humana
Corporate Medical Director - Medicare Grievances and Appeals
Humana, San Jose, California, United States, 95199
Join Our Dedicated Team and Make a Difference in Health Care!
The Corporate Medical Director serves as a pivotal leader in managing Medicare grievances and appeals by leveraging your medical expertise. In this role, you will review health claims, preservice appeals, and address complex issues that require innovative solutions.
You will make crucial medical interpretations regarding the appropriateness of services offered by healthcare professionals, ensuring compliance with internal review policies and performance standards. As a representative of Humana at Administrative Law Judge hearings, you will utilize your independent judgment to tackle challenging issues with minimal supervision.
Work hours are Monday through Friday, with occasional weekends. Key Responsibilities
Provide medical interpretations and decisions regarding service appropriateness. Ensure compliance with review policies and performance standards. Represent Humana during Administrative Law Judge hearings. Exercise independent judgment on complex medical issues. Required Qualifications
MD or DO degree. Current and unrestricted medical license in at least one jurisdiction; willingness to obtain licenses for other states as necessary. Board Certified in an approved ABMS Medical Specialty. Exceptional communication skills. A minimum of 5 years of clinical experience. Thorough understanding of the managed care industry, including Medicare and Medicaid. A passion for improving consumer experiences in healthcare. Preferred Qualifications
Experience in medical utilization management. Familiarity with health insurance organizations, hospitals, and patient interactions. Specialties in areas such as Internal Medicine, Family Practice, Geriatrics, and more are a plus. Remote Work Guidelines
This is a fully remote position with occasional travel for training or meetings at Humana offices. Your home internet connection should have a minimum download speed of 25 Mbps and an upload speed of 10 Mbps. Humana provides necessary telecommunication equipment and subsidizes internet expenses in certain states. You must work from a dedicated space that ensures member privacy and complies with HIPAA regulations. What We Offer: Humana offers comprehensive benefits that support your well-being and work-life balance, including medical, dental, and vision coverage, a 401(k) plan, generous paid time off, and various other benefits to support you and your family. Application Deadline: 11-30-2025 Why Humana?
At Humana, we prioritize the health of our team members, customers, and communities. Our mission is to simplify healthcare access and improve outcomes for millions we serve, including Medicare beneficiaries and military service personnel. Equal Opportunity Employer
Humana is dedicated to fostering a diverse and inclusive workplace, not discriminating based on race, gender, age, or any protected status. We actively seek to hire individuals who share our commitment to equity and inclusion.
Work hours are Monday through Friday, with occasional weekends. Key Responsibilities
Provide medical interpretations and decisions regarding service appropriateness. Ensure compliance with review policies and performance standards. Represent Humana during Administrative Law Judge hearings. Exercise independent judgment on complex medical issues. Required Qualifications
MD or DO degree. Current and unrestricted medical license in at least one jurisdiction; willingness to obtain licenses for other states as necessary. Board Certified in an approved ABMS Medical Specialty. Exceptional communication skills. A minimum of 5 years of clinical experience. Thorough understanding of the managed care industry, including Medicare and Medicaid. A passion for improving consumer experiences in healthcare. Preferred Qualifications
Experience in medical utilization management. Familiarity with health insurance organizations, hospitals, and patient interactions. Specialties in areas such as Internal Medicine, Family Practice, Geriatrics, and more are a plus. Remote Work Guidelines
This is a fully remote position with occasional travel for training or meetings at Humana offices. Your home internet connection should have a minimum download speed of 25 Mbps and an upload speed of 10 Mbps. Humana provides necessary telecommunication equipment and subsidizes internet expenses in certain states. You must work from a dedicated space that ensures member privacy and complies with HIPAA regulations. What We Offer: Humana offers comprehensive benefits that support your well-being and work-life balance, including medical, dental, and vision coverage, a 401(k) plan, generous paid time off, and various other benefits to support you and your family. Application Deadline: 11-30-2025 Why Humana?
At Humana, we prioritize the health of our team members, customers, and communities. Our mission is to simplify healthcare access and improve outcomes for millions we serve, including Medicare beneficiaries and military service personnel. Equal Opportunity Employer
Humana is dedicated to fostering a diverse and inclusive workplace, not discriminating based on race, gender, age, or any protected status. We actively seek to hire individuals who share our commitment to equity and inclusion.