Forensic medical examiner full time jobs

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Medical Director - Commercial
Carebridge 3.8
Columbus, OH
Medical Director- Commercial Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Prefer candidates to reside in the following states: CO, OH, IN, KY, MO, and WI. Schedule: Monday through Friday 8am-5pm CST or EST (If candidate is living in Colorado MST is fine). Weekend rotation coverage 5-6 weekends a year. The Medical Director will be part of the Central Region team responsible for utilization review case management and appeals for local Commercial business in the CO, OH, IN, KY, MO, and WI markets. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities. May serve as a resource to staff including Medical Director Associates. How you will make an impact: * Supports clinicians to ensure timely and consistent responses to members and providers. * Provides guidance for clinical operational aspects of a program. * Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients' office visits with providers and external physicians. * May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations. * Serves as a resource and consultant to other areas of the company. * May be required to represent the company to external entities and/or serve on internal and/or external committees. * May chair company committees. * Interprets medical policies and clinical guidelines. * May develop and propose new medical policies based on changes in healthcare. * Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes. * Identifies and develops opportunities for innovation to increase effectiveness and quality. Minimum Requirements: * Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA). * Must possess an active unrestricted medical license to practice medicine or a health profession. * Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US. * Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. * For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required. Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency. Preferred Qualifications: * General Surgeon or Primary Care specialties preferred. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $262,152 to $393,228 Locations: Colorado. In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
$262.2k-393.2k yearly Auto-Apply 60d+ ago
Medical Director - OneHome
Humana 4.8
Columbus, OH
**Become a part of our caring community and help us put health first** The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing home health, SNF, DME, dual Medicare/Medicaid and Waiver requests. 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. 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. The Medical Director works in a structured environment with expectations for consistency in thinking, authorship, meeting departmental expectations, and compliance timelines. **Use your skills to make an impact** 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 sanctions from Federal or State Governmental organizations + The ability to pass credentialing requirements + Excellent verbal and written communication skills with analytic and interpretative skills + Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution 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, Physiatry, Emergency Medicine, Critical Care 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 + Knowledge and experience with national guidelines such as NCD/LCD, MCG or InterQual The Medical Director conducts clinical case reviews of requests 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 call rotation which may include weekend coverage + Develop collaborative relationships with Team and key partners within the Medicare Line of Business. + Support Home Solutions as needed + Other activities as assigned by the managing Medical Director 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. $223,800 - $313,100 per year This 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: 12-30-2025 **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. 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 ***************************************************************************
$223.8k-313.1k yearly 38d ago
Medical Director -Spine
CVS Health 4.6
Delaware, OH
At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position SummaryAetna, a CVS Health Company, a Fortune 6 company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a remote based (work at home) based anywhere in the US. Aetna, a CVS Health Company, has an exciting opportunity for a Medical Director (Spine) that can be remote based, work from home. The Medical Director (Spine) will be a Subject Matter Expert (SME) with a background in Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically. Expands Aetna's medical management programs to address member needs across the continuum of care. Supports the Medical Management staff ensuring timely and consistent responses to members and providers. Leads all aspects of utilization review/quality assurance, directing case management Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities. Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise, using multiple computer based applications. Required Qualifications* 2 or more years of experience in Health Care Delivery System e. g. , Clinical Practice and Health Care Industry. * Active and current state medical license without encumbrances. * M. D. or D. O. , Board Certification in a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically. Preferred Qualifications* Previous healthcare insurance experience. Education* 2 or more years of experience in Health Care Delivery System e. g. , Clinical Practice and Health Care Industry. * Active and current state medical license without encumbrances. * M. D. or D. O. , Board Certification in a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience. Pay RangeThe typical pay range for this role is:$174,070. 00 - $374,920. 00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company's equity award program. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit ************* cvshealth. com/us/en/benefits We anticipate the application window for this opening will close on Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
$174.1k-374.9k yearly 31d ago
Medical Director Risk Management
Ohiohealth 4.3
Columbus, OH
**We are more than a health system. We are a belief system.** We believe wellness and sickness are both part of a lifelong partnership, and that everyone could use an expert guide. We work hard, care deeply and reach further to help people uncover their own power to be healthy. We inspire hope. We learn, grow, and achieve more - in our careers and in our communities. ** Summary:** The MDRM works daily with the Risk Managers and the lawyers and staff in the OGC addressing concerns impacting OhioHealth's liability with respect to professional liability claims and incidents and the review and oversight of practitioner claim trends from the organization's claims/incidence database. In partnering with System Quality, this role also identifies primary areas of risk and works with Quality to help focus on the organizational impact of risk, whether patient safety, reputational, or financial. This position will include reviewing potential claims for reporting to the OGC. This role is accountable for providing medical advice and support to the Risk Managers and OGC. This person must also be able to effectively work with the outside malpractice defense counsel to provide general medical advice with respect to malpractice claims defense when requested. The person will also support the patient grievance process at GMC and RMH. **Responsibilities And Duties:** 60% The Medical Director, Risk Management ("MDRM) will provide expertise and advice to support the Risk Management function throughout OhioHealth. The primary job duties of this individual are as follows, and as assigned: The MDRM will provide expert medical analysis of incidents, risk matters, and claims and may interact with patients and family regarding the same. The MDRM's general function is to be the primary medical expert/resource/advisor to the Risk Management department and the Office of the General Counsel ("OGC). This will include interaction with in-house lawyers and outside malpractice defense counsel on incidents and claims as requested. The MDRM will regularly attend the Risk Management/OGC Reserves meetings and provide advice and input on standard of care in connection with claims against OhioHealth for medical malpractice. The MDRM, in conjunction with the other OhioHealth Risk Managers, may from time to time cooperate and provide information and expertise to the Quality and Patient Safety and Peer Review staff and leadership to help manage risk and prevent patient care errors. The MDRM will be the primary medical expert reviewer of incidents and potentially compensable events (PCEs) as part of the OGC/RM "Significantly Involved Provider (SIP) program and provide SIP analyses to the Risk Managers and OGC lawyers managing litigation. 40% For Grant Medical Center (GMC) and Riverside Methodist Hospital (RMH), the MDRM will: Support, through collaboration with Patient Experience/Customer Service, the patient grievance process. In that regard, the MDRM will assist in or provide case evaluations, disclosures, review patient concerns and safety events, and make periodic calls and visits to patients and families when a physician or administrative representative is needed. The MDRM will attend the grievance committee meetings at GMC and RMH and participate in related system activities as appropriate. Support the campus VP of Clinical Affairs and collaborate with hospital leadership on matters affecting patient services. Oversee the system patient rights hotline and perform medical record reviews for potential patient harm as needed. **Minimum Qualifications:** Doctor of Osteopathic Medicine, Medical DoctorOLP - Ohio Licensed Physician - Ohio Medical Board **Additional Job Description:** **SPECIALIZED KNOWLEDGE** Experience in peer review, quality and safety. **Work Shift:** Day **Scheduled Weekly Hours :** 40 **Department** Legal Join us! ... if your passion is to work in a caring environment ... if you believe that learning is a life-long process ... if you strive for excellence and want to be among the best in the healthcare industry Equal Employment Opportunity OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all person in all aspects of the associate-employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment
$231k-325k yearly est. 60d+ ago
Associate Medical Director
MJ Morgan Group 3.6
Columbus, OH
Onsite | Full Time | Sign-On Bonus Our client is expanding their clinical leadership team in Columbus! We are looking for a mission-driven Associate Medical Director who is passionate about delivering high-quality, value-based care to medically complex and socially vulnerable populations. Our client provides a comprehensive, team-based model that integrates primary care, behavioral health, pharmacy, nutrition, imaging, community outreach, and more under one roof. What You'll Do Clinical Leadership & Care Delivery Provide exceptional primary care to a panel of members (70-80% clinical time). Lead and mentor physicians and APPs in delivering coordinated, high-touch care. Guide interdisciplinary teams (nursing, BH, care management, pharmacy, social work). Support daily population health huddles to drive quality and utilization outcomes. Operational & Strategic Impact Serve as a key clinical leader alongside the Medical Director. Represent the client with community partners, hospital systems, and payer organizations. Shape clinical protocols, care pathways, and support staff development. Collaborate across teams to meet engagement, quality, and cost-of-care goals. Member Care & Population Health Manage chronic and acute conditions, including urgent/same-day visits. Coordinate transitions of care across ER, hospital, SNF, and home settings. Utilize evidence-based practices and PCMH principles. Leverage EHR tools to track and achieve quality metrics. What You Bring Active, unrestricted medical or nursing license in Ohio. 5+ years of clinical experience with leadership of interdisciplinary teams. Background in outpatient clinics, community-based care, or inpatient settings. Experience mentoring clinicians and supporting clinical development. Strong communication, critical thinking, and organizational skills. Passion for population health, care transformation, and serving vulnerable communities. Ready to Make an Impact? Apply now to join a mission-driven team delivering transformative care. #HC123
$165k-333k yearly est. 37d ago
Part-time Behavioral Health Medical Director - Ohio
Centene Corporation 4.5
Columbus, OH
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. + Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. + Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. + Supports effective implementation of performance improvement initiatives for capitated providers. + Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. + Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. + Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. + Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. + Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. + Participates in provider network development and new market expansion as appropriate. + Assists in the development and implementation of physician education with respect to clinical issues and policies. + Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. + Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. + Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. + Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. + Develops alliances with the provider community through the development and implementation of the medical management programs. + As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. + Represents the business unit at appropriate state committees and other ad hoc committees. + May be required to work weekends and holidays in support of business operations, as needed. **Education/Experience:** + Medical Doctor or Doctor of Osteopathy. + Utilization Management experience and knowledge of quality accreditation standards preferred. + Actively practices medicine. + Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. + Experience treating or managing care for a culturally diverse population preferred. **License/Certifications:** + Board certification in general psychiatry or child psychiatry. + 5+ years of experience working in behavioral health managed care or behavioral health clinical settings, with at least 2 years in a clinical setting. + Certification in addiction medicine or in the sub-specialty of addiction psychiatry preferred. + Current OH state license as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $221,300.00 - $420,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
$221.3k-420.5k yearly 60d+ ago
Certification/Licensure Examiner 2
Dasstateoh
Columbus, OH
Certification/Licensure Examiner 2 (250009GK) Organization: Medical BoardAgency Contact Name and Information: ************************** Unposting Date: Dec 28, 2025, 11:59:00 PMPrimary Location: United States of America-OHIO-Franklin County-Columbus Compensation: PR 28 - $22.96 (Step 1) Schedule: Full-time Work Hours: 8:00 am - 5:00 pm Classified Indicator: ClassifiedUnion: OCSEA Primary Job Skill: Clerical & Data EntryTechnical Skills: Customer Service, Records ManagementProfessional Skills: Attention to Detail, Customer Focus, Teamwork, Confidentiality Agency OverviewAbout Us:The State Medical Board of Ohio issues licenses and oversees the practice of allopathic physicians (MD), osteopathic physicians (DO), podiatric physicians (DPM), massage therapists (LMT), and various other allied health care professionals under the authority of the Medical Practices Act, Chapter 4731, Ohio Revised Code (ORC). The Medical Board continues to regulate naprapaths and mechanotherapists licensed by the Board before March 1992.The Medical Board also regulates Physician Assistants, ORC Chapter 4730, Dietitians, ORC Chapter 4759, Anesthesiologist Assistants, ORC Chapter 4760, Respiratory Care Professionals, ORC Chapter 4761, Acupuncture, ORC Chapter 4762, ORC, Radiologist Assistants, ORC Chapter 4774, and Genetic Counselors, ORC Chapter 4778.The Medical Board's regulatory responsibilities include investigating complaints against applicants and licensees and taking disciplinary action against those who violate the public health and safety standards set by the General Assembly and the Medical Board.Our Mission:The State Medical Board of Ohio's mission is to protect and enhance the safety of the public through effective medical regulation.To find out more about the State Medical Board of Ohio click here.Job DescriptionClassification: Certification/Licensure Examiner 2Division: Licensure & RenewalLocation: 30 E. Broad Street - 3rd Floor, Columbus, OH 43215What You'll Do:We are seeking an applicant with excellent customer service skills to independently collaborate with our licensure team, assisting with licensure and renewal applications, license verifications, complaint filings, and investigatory procedures. The ideal candidate will work closely with both internal staff and external customers in a fast-paced call center environment, ensuring efficient and effective service delivery.Job duties include, but are not limited to:Responds to licensure & renewal inquiries & requests for information that require in-depth knowledge of applicable laws, rules, policies & procedures & independently determines appropriate action for resolution or referral.Explains licensure statutes, rules, requirements, procedures & Board policies in response to customer inquiries, customer needs & answers questions regarding licensure status, process, system issues, password & logon resets & related inquiries.Responds to inquiries from the public & licensees regarding licensure, renewal & Continuing Medical Education (CME).Assists with updating licensee information, processes requests for license verifications & duplicate wall certificates.Commits to satisfying internal & external customers by responding to requests in a timely manner, proactively identifies customer needs & referrals.Responds to inquiries regarding the Boards complaint filing & investigatory procedures.Processes complaints against licensees received via public website, email, mail, telephone hotline, the Federation of State Medical Boards (FSMB), & other sources.Refers complaints to appropriate department or staff members, refers non-jurisdictional complaints to other regulatory agencies as applicable.During peak licensure periods, independently examines & reviews incoming applications, credentials, renewal applications, reinstatement & restoration applications for physicians & other professions regulated by the Board.Provides clerical support.Works across departments & performs multidisciplinary cross coverage as needed.Why Work for the State of OhioAt the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes: Medical Coverage Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period Paid time off, including vacation, personal, sick leave and 11 paid holidays per year Childbirth, Adoption, and Foster Care leave Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more) Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation) *Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.Qualifications12 mos. trg. or 12 mos. exp. in reviewing applicants' eligibility to take examinations, test administration & scoring & compiling statistics concerning test results; 1 course or 3 mos. exp. in typing, word processing or data entry using video display terminal. -Or 2 yrs. trg. or 2 yrs. exp. in clerical/secretarial or other administrative support position involving public contact & preparation of correspondence & reports; 1 course or 3 mos. exp. in typing, word processing or data entry using video display terminal. -Or 12 mos. exp. as Certification/ Licensure Examiner 1, 16841. -Or equivalent of Minimum Class Qualifications For Employment noted above. Job Skills: Clerical & Data EntryTechnical Skills: Customer Service, Records ManagementProfessional Skills: Attention to Detail, Customer Focus, Teamwork, ConfidentialitySupplemental InformationPay Rates:Unless required by legislation or union contract, candidates can expect to be paid at the lowest rate in the salary range (Step 1).Application Process:All applicants are required to submit an application online. All answers to supplemental questions should be supported by the work experience/education section of your application. Applications that do not clearly indicate how the minimum qualifications are met will not be given consideration. Please do not use "see resume" as a substitute for completing the application in its entirety.Background Check:The final candidate selected for this position will be required to undergo a criminal background check. Criminal convictions do not necessarily preclude an applicant from consideration for a position. An individual assessment of an applicant's prior criminal convictions will be made before excluding an applicant from consideration.Status of Application: You can check the status of your application online by signing into your profile.The State Medical Board of Ohio is committed to providing access, inclusion and reasonable accommodation in its services, activities, programs, and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws. If contacted for an interview and you need to request a reasonable accommodation due to a disability, please contact Human Resources at ************************** no later than 14 days prior to the event.ADA StatementOhio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws.Drug-Free WorkplaceThe State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting.
$34k-54k yearly est. Auto-Apply 4h ago
Certification/Licensure Examiner 2
State of Ohio 4.5
Columbus, OH
Certification/Licensure Examiner 2 (250009IN) Organization: Occupational Therapy, Physical Therapy, and Athletic Trainers BoardAgency Contact Name and Information: Jennifer Gates, *************************** Unposting Date: Jan 6, 2026, 4:59:00 AMWork Location: Riffe Tower 16 77 South High Street 16th Floor Columbus 43215Primary Location: United States of America-OHIO-Franklin County-Columbus Compensation: $22.96/hr Schedule: Full-time Work Hours: 8:00AM-5:00PMClassified Indicator: ClassifiedUnion: OCSEA Primary Job Skill: Clerical & Data EntryTechnical Skills: Clerical & Data Entry, Administrative support/services Professional Skills: Attention to Detail, Interpreting Data, Organizing and Planning, Responsiveness, Time Management Agency OverviewThe Occupational Therapy, Physical Therapy, and Athletic Trainers (OTPTAT) Board's primary responsibility is to protect the citizens of the State of Ohio through the establishment of licensure and practice standards for the professional practice of occupational therapy, physical therapy, athletic training, orthotics, prosthetics, and pedorthics.Job DescriptionThe Certification/Licensure Examiner 2 plays an important part at the Board. In this role, you will be responsible for:Reviewing and processing pending occupational therapist, occupational therapy assistant, physical therapist, physical therapist assistant, athletic trainer, orthotist, prosthetist, prosthetist-orthotist, and pedorthist licensure applications Verifying accuracy and compliance with applicable laws, rules and procedures for licensure and registration, notes errors and discrepancies and initiates corrective action.Corresponding with applicants and licensees to correct problems Assisting licensees and applicants with accessing eLicense as well as other systems Displays clear written and verbal communication skills and strong customer service ethic Why Work for the State of OhioAt the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes: Medical Coverage Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period Paid time off, including vacation, personal, sick leave and 11 paid holidays per year Childbirth, Adoption, and Foster Care leave Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more) Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation) *Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.Qualifications12 months of training or 12 months of experience in reviewing applicants' eligibility to take examinations, test administration & scoring & compiling statistics concerning test results AND 1 course or 3 months of experience in typing, word processing or data entry using video display terminal. -OR 2 years of training or 2 years of experience in clerical/secretarial or other administrative support position involving public contact & preparation of correspondence & reports AND 1 course or 3 months of experience in typing, word processing or data entry using video display terminal. -OR 12 months of experience as Certification/ Licensure Examiner 1, 16841. -OR equivalent of Minimum Class Qualifications For Employment noted above. Job Skills: Clerical & Data EntrySupplemental InformationWhen completing your application, be sure to clearly describe how you meet the minimum qualifications outlined in this job posting. If you require reasonable accommodation for the application process, please email the Human Resources contact on this posting so arrangements can be made. The final candidate selected for this position will be required to undergo a criminal background check. Criminal convictions do not necessarily preclude an applicant from consideration for a position. An individual assessment of an applicant's prior criminal convictions will be made before excluding an applicant from consideration. ADA StatementOhio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws.Drug-Free WorkplaceThe State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting.
$23 hourly Auto-Apply 20h ago
Medical Director - IP Claims Management
Humana 4.8
Columbus, OH
**Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS and state policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare, Medicare Advantage, and Medicaid requirements and will understand how to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. May occasionally participate in discussions with external physicians by phone to gather additional clinical information or discuss determinations which may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, dispute, grievance, and appeals processes, and outpatient services and equipment, within their scope. The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value-based care, population health, or disease or care management. Medical Directors support Humana values throughout all activities. **Use your skills to make an impact** **Responsibilities** The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS and state Medicaid requirements, Humana policies, clinical standards, and (in some cases) contracts. The ideal candidate supports and collaborates with other team members, other departments, and Humana colleagues. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. Supports the assigned work with respect to market-wide objectives and community relations as directed. **Required Qualifications** + MD or DO degree + 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). + Current and ongoing Board Certification an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s), if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills. + 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. **Preferred Qualifications** + 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. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. + Experience with national guidelines such as MCG or InterQual + Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists + Advanced degree such as an MBA, MHA, MPH + Exposure to Public Health, Population Health, analytics, and use of business metrics. + Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health. + The curiosity to learn, the flexibility to adapt and the courage to innovate **Additional Information** Typically reports to a Lead Medical Director, depending on the line of business. The Medical Director conducts Utilization Management or clinical validation of the care received by members in an assigned line of business, member population, or condition type. May also engage in dispute, grievance, and appeals reviews. May participate on project teams or organizational committees. \#physiciancareers 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. $223,800 - $313,100 per year This 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: 02-28-2026 **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. 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 ***************************************************************************
$223.8k-313.1k yearly 21d ago
Utilization Management Medical Director- NC Medicaid
Carebridge 3.8
Columbus, OH
Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Ideal candidate will live in North Carolina but not required. Alternate locations may be considered. The Medical Director will be responsible for utilization review case management for North Carolina Medicaid. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities. May serve as a resource to staff including Medical Director Associates. How you will make an impact: * Supports clinicians to ensure timely and consistent responses to members and providers. * Provides guidance for clinical operational aspects of a program. * Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients' office visits with providers and external physicians. * May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations. * Serves as a resource and consultant to other areas of the company. * May be required to represent the company to external entities and/or serve on internal and/or external committees. * May chair company committees. * Interprets medical policies and clinical guidelines. * May develop and propose new medical policies based on changes in healthcare. * Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes. * Identifies and develops opportunities for innovation to increase effectiveness and quality. Minimum Requirements: * Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA). * Must possess an active unrestricted medical license to practice medicine or a health profession in North Carolina. * Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US. * Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. * For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required. Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency. Preferred Qualifications: * Pediatrics board certification preferred. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
$170k-258k yearly est. Auto-Apply 60d+ ago
Medical Director -Spine
CVS Health 4.6
Delaware, OH
At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position SummaryAetna, a CVS Health Company, a Fortune 6 company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a remote based (work at home) based anywhere in the US. Aetna, a CVS Health Company, has an exciting opportunity for a Medical Director (Spine) that can be remote based, work from home. The Medical Director (Spine) will be a Subject Matter Expert (SME) with a background in Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically. Expands Aetna's medical management programs to address member needs across the continuum of care. Supports the Medical Management staff ensuring timely and consistent responses to members and providers. Leads all aspects of utilization review/quality assurance, directing case management Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities. Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise, using multiple computer based applications. Required Qualifications* 2 or more years of experience in Health Care Delivery System e. g. , Clinical Practice and Health Care Industry. * Active and current state medical license without encumbrances. * M. D. or D. O. , Board Certification in a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically. Preferred Qualifications* Previous healthcare insurance experience. Education* 2 or more years of experience in Health Care Delivery System e. g. , Clinical Practice and Health Care Industry. * Active and current state medical license without encumbrances. * M. D. or D. O. , Board Certification in a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience. Pay RangeThe typical pay range for this role is:$174,070. 00 - $374,920. 00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company's equity award program. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit ************* cvshealth. com/us/en/benefits We anticipate the application window for this opening will close on: 01/30/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
$174.1k-374.9k yearly 6d ago
Certification/Licensure Examiner 2
Dasstateoh
Columbus, OH
Certification/Licensure Examiner 2 (250009IN) Organization: Occupational Therapy, Physical Therapy, and Athletic Trainers BoardAgency Contact Name and Information: Jennifer Gates, *************************** Unposting Date: Jan 6, 2026, 4:59:00 AMWork Location: Riffe Tower 16 77 South High Street 16th Floor Columbus 43215Primary Location: United States of America-OHIO-Franklin County-Columbus Compensation: $22.96/hr Schedule: Full-time Work Hours: 8:00AM-5:00PMClassified Indicator: ClassifiedUnion: OCSEA Primary Job Skill: Clerical & Data EntryTechnical Skills: Clerical & Data Entry, Administrative support/services Professional Skills: Attention to Detail, Interpreting Data, Organizing and Planning, Responsiveness, Time Management Agency OverviewThe Occupational Therapy, Physical Therapy, and Athletic Trainers (OTPTAT) Board's primary responsibility is to protect the citizens of the State of Ohio through the establishment of licensure and practice standards for the professional practice of occupational therapy, physical therapy, athletic training, orthotics, prosthetics, and pedorthics.Job DescriptionThe Certification/Licensure Examiner 2 plays an important part at the Board. In this role, you will be responsible for:Reviewing and processing pending occupational therapist, occupational therapy assistant, physical therapist, physical therapist assistant, athletic trainer, orthotist, prosthetist, prosthetist-orthotist, and pedorthist licensure applications Verifying accuracy and compliance with applicable laws, rules and procedures for licensure and registration, notes errors and discrepancies and initiates corrective action.Corresponding with applicants and licensees to correct problems Assisting licensees and applicants with accessing eLicense as well as other systems Displays clear written and verbal communication skills and strong customer service ethic Why Work for the State of OhioAt the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes: Medical Coverage Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period Paid time off, including vacation, personal, sick leave and 11 paid holidays per year Childbirth, Adoption, and Foster Care leave Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more) Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation) *Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.Qualifications12 months of training or 12 months of experience in reviewing applicants' eligibility to take examinations, test administration & scoring & compiling statistics concerning test results AND 1 course or 3 months of experience in typing, word processing or data entry using video display terminal. -OR 2 years of training or 2 years of experience in clerical/secretarial or other administrative support position involving public contact & preparation of correspondence & reports AND 1 course or 3 months of experience in typing, word processing or data entry using video display terminal. -OR 12 months of experience as Certification/ Licensure Examiner 1, 16841. -OR equivalent of Minimum Class Qualifications For Employment noted above. Job Skills: Clerical & Data EntrySupplemental InformationWhen completing your application, be sure to clearly describe how you meet the minimum qualifications outlined in this job posting. If you require reasonable accommodation for the application process, please email the Human Resources contact on this posting so arrangements can be made. The final candidate selected for this position will be required to undergo a criminal background check. Criminal convictions do not necessarily preclude an applicant from consideration for a position. An individual assessment of an applicant's prior criminal convictions will be made before excluding an applicant from consideration. ADA StatementOhio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws.Drug-Free WorkplaceThe State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting.
$23 hourly Auto-Apply 4h ago
Certification/Licensure Examiner 2
State of Ohio 4.5
Columbus, OH
The Certification/Licensure Examiner 2 plays an important part at the Board. In this role, you will be responsible for: Reviewing and processing pending occupational therapist, occupational therapy assistant, physical therapist, physical therapist assistant, athletic trainer, orthotist, prosthetist, prosthetist-orthotist, and pedorthist licensure applications Verifying accuracy and compliance with applicable laws, rules and procedures for licensure and registration, notes errors and discrepancies and initiates corrective action. Corresponding with applicants and licensees to correct problems Assisting licensees and applicants with accessing eLicense as well as other systems Displays clear written and verbal communication skills and strong customer service ethic The State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting. 12 months of training or 12 months of experience in reviewing applicants' eligibility to take examinations, test administration & scoring & compiling statistics concerning test results AND 1 course or 3 months of experience in typing, word processing or data entry using video display terminal. -OR 2 years of training or 2 years of experience in clerical/secretarial or other administrative support position involving public contact & preparation of correspondence & reports AND 1 course or 3 months of experience in typing, word processing or data entry using video display terminal. -OR 12 months of experience as Certification/ Licensure Examiner 1, 16841. -OR equivalent of Minimum Class Qualifications For Employment noted above. Job Skills: Clerical & Data Entry Ohio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws. When completing your application, be sure to clearly describe how you meet the minimum qualifications outlined in this job posting. If you require reasonable accommodation for the application process, please email the Human Resources contact on this posting so arrangements can be made. The final candidate selected for this position will be required to undergo a criminal background check. Criminal convictions do not necessarily preclude an applicant from consideration for a position. An individual assessment of an applicant's prior criminal convictions will be made before excluding an applicant from consideration. The Occupational Therapy, Physical Therapy, and Athletic Trainers (OTPTAT) Board's primary responsibility is to protect the citizens of the State of Ohio through the establishment of licensure and practice standards for the professional practice of occupational therapy, physical therapy, athletic training, orthotics, prosthetics, and pedorthics. At the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes: Medical Coverage Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period Paid time off, including vacation, personal, sick leave and 11 paid holidays per year Childbirth, Adoption, and Foster Care leave Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more) Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation) *Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.
$31k-41k yearly est. Auto-Apply 3d ago
Medical Director - Nat'l UM Team 1wknd/mo
Humana 4.8
Columbus, OH
**Become a part of our caring community and help us put health first** Become a part of our caring community and help us put health first 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. All work occurs within 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 reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. Weekend work required one weekend per month with compensated days off during the work week The Medical Director's work includes reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative professional relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment. Medical Directors support Humana value throughout all activities. **Responsibilities** The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. The ideal candidate enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. + Conduct comprehensive, timely, and compliant medical necessity reviews for inpatient services + Maintain accountability for productivity, quality, and compliance metrics + Communicate determinations clearly both verbally and in writing + Demonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practices + **Weekend work required one weekend per month with compensated days off during the work week** **Use your skills to make an impact** **Use your skills to make an impact** **Required Qualifications** + MD or DO degree + 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). + Current and ongoing Board Certification an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills. + Evidence of analytic and interpretation skills, with prior experience working in a team environment **Preferred Qualifications** + 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, or other healthcare providers. + Utilization management experience in a medical management review organization, such as Medicare Advantage, Managed Medicaid, or Commercial health insurance. + Experience with national guidelines such as MCG or InterQual + Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and hospital-based clinical specialists + The curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals. + Ability to thrive in a dynamic fast-paced, team-oriented environment. + Commitment to a culture of innovation, including being facile with using technology to improve workflows + Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution + Passionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team culture **Additional Information** The medical director reports to a Lead Medical Director. Participation in weekend work on a rotational basis to ensure cases are decisioned in a timely manner May participate on project teams or organizational committees. \#physiciancareers 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. $223,800 - $313,100 per year This 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: 04-30-2026 **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. 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 ***************************************************************************
$223.8k-313.1k yearly 45d ago
Certification/Licensure Examiner 2
State of Ohio 4.5
Columbus, OH
The State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting. About Us: The State Medical Board of Ohio issues licenses and oversees the practice of allopathic physicians (MD), osteopathic physicians (DO), podiatric physicians (DPM), massage therapists (LMT), and various other allied health care professionals under the authority of the Medical Practices Act, Chapter 4731, Ohio Revised Code (ORC). The Medical Board continues to regulate naprapaths and mechanotherapists licensed by the Board before March 1992. The Medical Board also regulates Physician Assistants, ORC Chapter 4730, Dietitians, ORC Chapter 4759, Anesthesiologist Assistants, ORC Chapter 4760, Respiratory Care Professionals, ORC Chapter 4761, Acupuncture, ORC Chapter 4762, ORC, Radiologist Assistants, ORC Chapter 4774, and Genetic Counselors, ORC Chapter 4778. The Medical Board's regulatory responsibilities include investigating complaints against applicants and licensees and taking disciplinary action against those who violate the public health and safety standards set by the General Assembly and the Medical Board. Our Mission: The State Medical Board of Ohio's mission is to protect and enhance the safety of the public through effective medical regulation. To find out more about the State Medical Board of Ohio click here. Pay Rates: Unless required by legislation or union contract, candidates can expect to be paid at the lowest rate in the salary range (Step 1). Application Process: All applicants are required to submit an application online. All answers to supplemental questions should be supported by the work experience/education section of your application. Applications that do not clearly indicate how the minimum qualifications are met will not be given consideration. Please do not use "see resume" as a substitute for completing the application in its entirety. Background Check: The final candidate selected for this position will be required to undergo a criminal background check. Criminal convictions do not necessarily preclude an applicant from consideration for a position. An individual assessment of an applicant's prior criminal convictions will be made before excluding an applicant from consideration. Status of Application\: You can check the status of your application online by signing into your profile. The State Medical Board of Ohio is committed to providing access, inclusion and reasonable accommodation in its services, activities, programs, and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws. If contacted for an interview and you need to request a reasonable accommodation due to a disability, please contact Human Resources at ************************** no later than 14 days prior to the event. At the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes: Medical Coverage Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period Paid time off, including vacation, personal, sick leave and 11 paid holidays per year Childbirth, Adoption, and Foster Care leave Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more) Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation) *Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position. 12 mos. trg. or 12 mos. exp. in reviewing applicants' eligibility to take examinations, test administration & scoring & compiling statistics concerning test results; 1 course or 3 mos. exp. in typing, word processing or data entry using video display terminal. -Or 2 yrs. trg. or 2 yrs. exp. in clerical/secretarial or other administrative support position involving public contact & preparation of correspondence & reports; 1 course or 3 mos. exp. in typing, word processing or data entry using video display terminal. -Or 12 mos. exp. as Certification/ Licensure Examiner 1, 16841. -Or equivalent of Minimum Class Qualifications For Employment noted above. Job Skills\: Clerical & Data Entry Technical Skills\: Customer Service, Records Management Professional Skills\: Attention to Detail, Customer Focus, Teamwork, Confidentiality Ohio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws. Classification: Certification/Licensure Examiner 2 Division: Licensure & Renewal Location: 30 E. Broad Street - 3rd Floor, Columbus, OH 43215 What You'll Do: We are seeking an applicant with excellent customer service skills to independently collaborate with our licensure team, assisting with licensure and renewal applications, license verifications, complaint filings, and investigatory procedures. The ideal candidate will work closely with both internal staff and external customers in a fast-paced call center environment, ensuring efficient and effective service delivery. Job duties include, but are not limited to: Responds to licensure & renewal inquiries & requests for information that require in-depth knowledge of applicable laws, rules, policies & procedures & independently determines appropriate action for resolution or referral. Explains licensure statutes, rules, requirements, procedures & Board policies in response to customer inquiries, customer needs & answers questions regarding licensure status, process, system issues, password & logon resets & related inquiries. Responds to inquiries from the public & licensees regarding licensure, renewal & Continuing Medical Education (CME). Assists with updating licensee information, processes requests for license verifications & duplicate wall certificates. Commits to satisfying internal & external customers by responding to requests in a timely manner, proactively identifies customer needs & referrals. Responds to inquiries regarding the Boards complaint filing & investigatory procedures. Processes complaints against licensees received via public website, email, mail, telephone hotline, the Federation of State Medical Boards (FSMB), & other sources. Refers complaints to appropriate department or staff members, refers non-jurisdictional complaints to other regulatory agencies as applicable. During peak licensure periods, independently examines & reviews incoming applications, credentials, renewal applications, reinstatement & restoration applications for physicians & other professions regulated by the Board. Provides clerical support. Works across departments & performs multidisciplinary cross coverage as needed.
$31k-41k yearly est. Auto-Apply 8d ago
Medical Director - Nat'l IP UM Team
Humana 4.8
Columbus, OH
**Become a part of our caring community and help us put health first** Become a part of our caring community and help us put health first 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. All work occurs within 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 reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. The Medical Director's work includes reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative professional relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment. Medical Directors support Humana value throughout all activities. **Responsibilities** The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. The ideal candidate enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. + Conduct comprehensive, timely, and compliant medical necessity reviews for inpatient services + Maintain accountability for productivity, quality, and compliance metrics + Communicate determinations clearly both verbally and in writing + Participate in rotational weekend work and occasional holiday responsibilities + Demonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practices **Work Schedule Monday - Friday w/standard weekends (about 5 per year on average) Eastern Time Zone hours** **Use your skills to make an impact** **Use your skills to make an impact** **Required Qualifications** + MD or DO degree + 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). + Current and ongoing Board Certification an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills. + Evidence of analytic and interpretation skills, with prior experience working in a team environment + **Work Schedule Monday - Friday w/standard weekends (about 5 per year on average) Eastern Time Zone hours** **Preferred Qualifications** + 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, or other healthcare providers. + Utilization management experience in a medical management review organization, such as Medicare Advantage, Managed Medicaid, or Commercial health insurance. + Experience with national guidelines such as MCG or InterQual + Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and hospital-based clinical specialists + The curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals. + Ability to thrive in a dynamic fast-paced, team-oriented environment. + Commitment to a culture of innovation, including being facile with using technology to improve workflows + Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution + Passionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team culture **Additional Information** The medical director reports to a Lead Medical Director. Participation in weekend work on a rotational basis to ensure cases are decisioned in a timely manner May participate on project teams or organizational committees. \#physiciancareers 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. $223,800 - $313,100 per year This 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: 04-30-2026 **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. 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 ***************************************************************************
$223.8k-313.1k yearly 42d ago
Medical Director - OP Claims Mgmt
Humana 4.8
Columbus, OH
**Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized at the Initial and Appeals/Disputes level. All work occurs within 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 reference sources. Medical Directors will learn Medicare, Medicaid, and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. The clinical scenarios predominantly arise from outpatient, inpatient or post-acute care environments. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, disputes processes, and appeals processes, and outpatient services and equipment, within their scope. The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value based care, population health, or disease or care management. **Use your skills to make an impact** **Responsibilities** 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. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines. **Required Qualifications** + MD or DO degree + 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient/outpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age). + Current and ongoing Board Certification an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills . + 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. **Preferred Qualifications** + 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. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. + Experience with national guidelines such as MCG or InterQual + Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists + Advanced degree such as an MBA, MHA, MPH + Exposure to Public Health, Population Health, analytics, and use of business metrics. + Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health. + The curiosity to learn, the flexibility to adapt and the courage to innovate + Ability to obtain additional medical licenses **Additional Information** Typically reports to Lead depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May also engage in disputes and appeals reviews. May participate on project teams or organizational committees. \#physiciancareers 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. $223,800 - $313,100 per year This 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: 01-31-2026 **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. 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 ***************************************************************************
$223.8k-313.1k yearly 32d ago
Medical Director - Pharmacy Appeals
Humana 4.8
Columbus, OH
**Become a part of our caring community and help us put health first** The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments involve moderately complex to complex issues where the analysis of situations or data requires a case by case consideration of the Medicare rules, Humana policies and medical necessity. The Medical Director will collaborate with clinicians and support staff to provide Humana members with optimal value based care in accordance with Medicare and Humana policy. All work occurs within a context of regulatory compliance and work is assisted by diverse resources, included but not limited to CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature as appropriate. Medical Directors will learn Medicare Part D and Medicare Advantage requirements and will understand how to operationalize this in their daily work. The Medical Director's work includes computer based review of moderately complex to complex appeals for coverage for drugs using resources outlined above as well as inter- and intra-departmental resources. Work may include Peer to Peer discussions with prescribers, participation in hearings involving an Administrative Law Judge, support for CMS audits, cross-functional team activities, and other responsibilities as determined necessary to support optimal value based care in accordance with Medicare and Humana policy. **Use your skills to make an impact** **Required Qualifications:** + MD or DO degree + 5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience related to a Medicare type population (disabled or >65 years of age) + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements + Excellent verbal and written communication skills + Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, or similar activities **Preferred Qualifications:** + Knowledge of the managed care industry, Integrated Delivery Systems, health insurance, or clinical group practice management + Utilization management experience in a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial health insurance + Current and ongoing Board Certification in Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation + Experience with national guidelines, such as MCG, InterQual, NCCN, Micromedex, Lexicomp, Elsevier's Clinical Pharmacology + Exposure to Public Health, Population Health, analytics, and use of business metrics + Curiosity to learn, flexibility to adapt, courage to innovate + Experience functioning as a Team member, providing support to reach a common goal **Additional Information** May participate on project teams or organizational committees. \#physiciancareers 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. $223,800 - $313,100 per year This 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: 01-31-2026 **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. 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 ***************************************************************************
$223.8k-313.1k yearly 24d ago
Medical Director - Nat'l UM Team Alt Weekends
Humana 4.8
Columbus, OH
**Become a part of our caring community and help us put health first** Become a part of our caring community and help us put health first 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. All work occurs within 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 reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. Willingness to work every other weekend with compensated days off during the work week The Medical Director's work includes reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative professional relationships. The ideal candidate will have a high degree of integrity, professionalism, resourcefulness, and enjoy working in a team-based environment. Medical Directors support Humana value throughout all activities. **Responsibilities** The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. The ideal candidate enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. + Conduct comprehensive, timely, and compliant medical necessity reviews for inpatient services + Maintain accountability for productivity, quality, and compliance metrics + Communicate determinations clearly both verbally and in writing + Demonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practices + **Willingness to work every other weekend with compensated days off during the work week** **Use your skills to make an impact** **Use your skills to make an impact** **Required Qualifications** + MD or DO degree + 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). + Current and ongoing Board Certification an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills. + Evidence of analytic and interpretation skills, with prior experience working in a team environment **Preferred Qualifications** + 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, or other healthcare providers. + Utilization management experience in a medical management review organization, such as Medicare Advantage, Managed Medicaid, or Commercial health insurance. + Experience with national guidelines such as MCG or InterQual + Experience in hospital-based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and hospital-based clinical specialists + The curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals. + Ability to thrive in a dynamic fast-paced, team-oriented environment. + Commitment to a culture of innovation, including being facile with using technology to improve workflows + Participate in educational activities by attending required conferences and also create content to lead/teach/present for individual subject matter contribution + Passionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team culture **Additional Information** The medical director reports to a Lead Medical Director. Participation in weekend work on a rotational basis to ensure cases are decisioned in a timely manner May participate on project teams or organizational committees. \#physiciancareers 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. $223,800 - $313,100 per year This 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: 02-28-2026 **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. 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 ***************************************************************************
$223.8k-313.1k yearly 45d ago
Medical Director-Payment Integrity
Humana 4.8
Columbus, OH
**Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized at the Inpatient level. All work occurs within 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 reference sources. Medical Directors will learn Medicare, Medicaid, and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work and communication of decisions to internal associates. The clinical scenarios predominantly arise from inpatient or post-acute care environments. A remote possibility exists of doing peer-to-peer discussions with an external provider. Some roles include an overview of coding practices and clinical documentation, dispute/grievance and appeals processes, and outpatient services and equipment, within their scope. Medical Directors support Humana values, and Humana's mission, throughout all activities. **Use your skills to make an impact** **Responsibilities** 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. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Lead Medical Director. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines. Supports the assigned work with respect to market-wide objectives and community relations as directed. **Required Qualifications** + MD or DO degree + 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age). + Current and ongoing Board Certification an approved ABMS Medical Specialty + A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required. + No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. + Excellent verbal and written communication skills. + 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. **Preferred Qualifications** + 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. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. + Experience with national guidelines such as MCG or InterQual + Internal Medicine, Hospitalist, Family Practice, Geriatrics, Emergency Medicine clinical specialists + Advanced degree such as an MBA, MHA, MPH + Exposure to Public Health, Population Health, analytics, and use of business metrics. + The curiosity to learn, the flexibility to adapt and the courage to innovate **Additional Information** Typically reports to a Lead Medical Director. The Medical Director conducts post-service, inpatient care reviews for accurate billing of clinically valid diagnoses and care received. May also engage in disputes and grievance and appeals reviews. May participate on project teams or organizational committees. \#physiciancareers 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. $223,800 - $313,100 per year This 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: 02-28-2026 **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. 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 ***************************************************************************
$223.8k-313.1k yearly 16d ago

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