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Job Details

Grievances and Appeals Medical Director - Nationwide

Company name
Humana Inc.

Riverton, WY, United States

Employment Type

Healthcare, Manager

Posted on
Apr 11, 2023

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The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing appeals for Medicare Part C Line of Business. 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. Candidates may live anywhere in the US but MUST work East Coast hours. This position will work weekend days on a rotating basis


The 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. All work occurs with a context of regulatory compliance, and work is assisted by diverse resources which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to operationalize this knowledge in their daily work. After completion of mentored training, daily work is performed with minimal direction. The Medical Director works in a structured environment with expectations for consistency in thinking, authorship, meeting departmental expectations, and compliance timelines. Weekend rotation is between every 5 to 7 weeks, working both Saturday and Sunday (8 hours per day) with two days off during the week.

Required Qualifications

MD or DO degree

Current and ongoing board certification in an approved ABMS Medical Specialty

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

5 years of direct clinical patient care experience post residency or fellowship

No current sanction from Federal or State Governmental organizations

The ability to pass credentialing requirements

Excellent verbal and written communication skills with analytic and interpretative skills

Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual

Preferred Qualifications

Experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)

Internal Medicine, Family Practice, Geriatrics, or hospital based clinical specialists

Ability to function in a dynamic fast paced environment

Commitment to a culture of innovation

Passionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team culture

The Medical Director conducts clinical case reviews of the appeals received by members of the Medicare population and reports to the Lead Medical Director.

Other duties:

Identify medical management operational improvements, including those within the medical director area

Participate in weekend work rotation

Develop collaborative relationships with Team and key partners within the Medicare Line of Business.

Support G&A MD Team engagement, operational, and other meetings

Other activities as assigned by the Lead Medical Director

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

Scheduled Weekly Hours


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. We also provide free language interpreter services. See our

Company info

Humana Inc.
Website :

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