Medical Director Grievances & Appeals

Humana

2d • $246,100 - $344,200 • Remote

About The Position

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

Requirements

• 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 of established clinical experience
• Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
• Possess analysis and interpretation skills with prior experience leading teams focusing on quality management.
• Experience with discharge planning and/or home health or rehab
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Nice To Haves

• Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
• Internal Medicine, Family Practice, Geriatrics, Hospitalist clinical specialists

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 Humana’s 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.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree