- Humana (Boston, MA)
- …or data requires an in-depth evaluation of variable factors. The Medical Director for the National Medicare Outpatient Team provides medical ... caring community and help us put health first** The Medical Director relies on medical ...or Surgery specialties + Utilization management experience in a medical management review organization, such as Medicare … more
- Humana (Boston, MA)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims and ... preservice appeals. The Corporate Medical Director works on problems of diverse...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Must be… more
- Elevance Health (Woburn, MA)
- …deliver member-centered, lasting pharmacy care. In this pivotal role on our CarelonRx Medicare Sales and Account Management team, the Pharmacy Account Director ... preserving and deepening relationships with clients which include Elevance Health Medicare Health Plans. This position, structured around geographic regions and… more
- Point32Health (Canton, MA)
- …are approved by senior leadership, the Senior Manager, in collaboration with the Director , is responsible for all necessary product filings with CMS and other ... business performance needs of each market. All responsibilities extend to any new Medicare markets should Point32Health choose to expand its footprint in the future.… more
- Humana (Boston, MA)
- …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 ... provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and... Medicare population and reports to the Lead Medical Director . **Other duties:** + Identify … more
- Humana (Boston, MA)
- …clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments involve moderately complex to complex issues where the ... of the Medicare rules, Humana policies and medical necessity. The Medical Director ...diverse resources, included but not limited to CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana… more
- Humana (Boston, MA)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and ...to operationalize this knowledge in their daily work. The Medical Director 's work includes reviewing of all… more
- Humana (Boston, MA)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... will understand how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of moderately complex to… more
- Humana (Boston, MA)
- **Become a part of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement ... will understand how to operationalize this knowledge in their daily work. The Medical Director 's work includes computer-based review of moderately complex to… more
- Evolent Health (Boston, MA)
- …Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Medical Director for the Musculoskeletal department, you will be a key member of ... questions. + Reviews statistical sample of cases for Field Medical Director audits and makes recommendations into...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Advocates (Framingham, MA)
- …that values the ideas and contributions of our staff. The Behavioral Health Regional Medical Director (RMD) is a leadership and clinical role within Advocates' ... Behavioral Health Services Division. The RMD serves as Medical Director for the clinics of an...a minimum of $1,000,000/$3,000,000. + Satisfactory report from the National Practitioner Data Bank and absence of Medicare… more
- Gilead Sciences, Inc. (Boston, MA)
- …the lives of patients with life-threatening illnesses worldwide. As the **Senior Director , Field Reimbursement Management (FRM)** for HIV Prevention, you will play a ... with pharmacy benefits, specialty payer landscape, and reimbursement pathways (commercial, Medicare , Medicaid). + An understanding of local and state policy changes'… more
- Humana (Boston, MA)
- …caring community and help us put health first** The Associate Director , Actuarial Analytics/Forecasting analyzes and forecasts financial, economic, and other data ... medium and long-term financial and competitive position. The Associate Director , Actuarial Analytics/Forecasting requires a solid understanding of how organization… more
- Fallon Health (Worcester, MA)
- …**Brief Summary of Purpose:** With general direction from the Vice President and Senior Medical Director of Quality and Population Health, the Director of ... for Quality Assurance standards, the regulations promulgated by the Centers of Medicare and Medicaid, the Massachusetts Division of Medical Assistance, and… more
- Humana (Boston, MA)
- …our caring community and help us put health first** The Associate Director , Cloud Architecture designs, builds, and maintains data processing architectures and ... and unstructured data to insights at enterprise scale. The Associate Director , Cloud Architecture requires an in-depth understanding of how organization capabilities… more
- Commonwealth Care Alliance (Boston, MA)
- **Why This Role is Important to Us:** The Director of Utilization Management leads and manages all utilization management (UM) functions for physical health services ... federal regulatory requirements and all applicable accreditation standards. The Director of Utilization Management is responsible for setting strategic direction,… more
- Tufts Medicine (Burlington, MA)
- …liaison to various payers including Medicare Shared Savings Program (MSSP), Medicare Advantage programs, and local and national commercial insurers. 13. ... throughout the greater Boston region. **What you will do:** Our new Director Regional Operations for Tufts Medicine Integrated Network (TMIN) reporting to the… more
- Olympus Corporation of the Americas (Westborough, MA)
- …**__** Every day, we live by our philosophy, True to Life, by advancing medical technologies and elevating the standard of patient care so people everywhere can ... entity other than @Olympus.com, it is likely not legitimate._ **Job Description** The Director , Global Health Economics & Market Access is part of Health Economics &… more
- CVS Health (Boston, MA)
- …care more personal, convenient and affordable. **Job Purpose and Summary:** The Dental Director - Medicare Appeals is an individual contributor who will assure ... + Basic knowledge of dental benefit products and platforms (DMO, PPO, Medicare Advantage) + Strong understanding of clinical quality programs, and clinical… more
- Prime Therapeutics (Boston, MA)
- …legislative/oversight bodies (eg, URAC-Utilization Review Accreditation Commission, CMS-Centers for Medicare & Medicaid Services, NCQA- National Committee for ... passion and drives every decision we make. **Job Posting Title** Director , Specialty Clinical Solutions- RPH/PharmD required- REMOTE **Job Description Summary**… more