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The ideal candidate will be well versed in the Medicare managed care appeals and grievance process. 3 to 5+ years of recent experience writing insurance appeals and pursuing Medicare for collection on behalf of hospitals (facility charges.
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Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or states.
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May also engage in grievance and appeals reviews. 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.
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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.
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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.
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Become a part of our caring community and help us put health first. 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.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company.
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Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities/auditors related to medical necessity and/or level of care.
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Exposure to Public Health, Population Health, analytics, and use of business metrics. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type.
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Must be able to collect clinical data from inpatient and outpatient sources; provide documentation for appeals or grievance resolution; apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations; apply problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.
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The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts.
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Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion.
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Minimum of 3 years recent Managed Care experience in Provider Relations, Network Operations, and/or Network Management. Assists in creation of reports, attends, and presents at Plan committee meetings (Grievance, SIC, etc.
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The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, level of care, and/or site of service should be authorized.
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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.
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grievance appeals and managed care jobs
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