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The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, Uses independent judgment requiring analysis of variable factors and determining the best course of action.
TheCorporate Medical Director provides medical interpretation, clinical review, and strategic medical leadership to support Humana’s OneHome initiatives. This role reviews health claims and clinical requests to determine the appropriateness and medical necessity of services provided by healthcare professionals, including Home Care Solutions, Skilled Nursing Facility, Durable Medical Equipment, rehabilitation, discharge planning, and related home care solutions.
Clinical Review and Medical Necessity Determinations
Review clinical cases, health claims, and service requests to determine the medical necessity and appropriateness of care provided by healthcare professionals.
Evaluate requests involving Home Care Solutions, Skilled Nursing Facility services, Durable Medical Equipment, rehabilitation, discharge planning, and other home-based care solutions.
Apply CMS Medicare guidance, Medicare Advantage requirements, Medicaid requirements, national clinical guidelines, Humana policies, clinical standards, review procedures, performance standards, and applicable contracts.
Provide medical interpretation and clinical rationale for determinations involving Medicare, Medicaid, Commercial, and dual-eligible populations, as applicable.
Ensure decisions are timely, fair, consistent, compliant, and evidence based.
Analyze complex clinical scenarios and variable factors to determine the most appropriate course of action.
Strategic Medical Leadership
Advise executives and business leaders on functional strategies related to OneHome and segment-specific clinical priorities.
Serve as a clinical subject matter expert on matters of significance involving home-based care, post-acute services, utilization management, quality management, discharge planning, and care coordination.
Exercise independent judgment and decision-making on complex issues related to clinical review operations and medical management strategy.
Support the development and refinement of policies, procedures, workflows, and performance standards that improve review quality and operational consistency.
Contribute to scalable strategies that support OneHome and the evolving needs of Medicare, Medicaid, Commercial, and dual-eligible populations.
Operational Improvement and Performance Support
Identify opportunities to improve medical management operations, workflow efficiency, case turnaround times, review consistency, and service delivery.
Analyze clinical information, utilization patterns, operational data, and performance trends to identify gaps, risks, and opportunities.
Support initiatives focused on quality management, utilization management, discharge planning, home care solutions, rehabilitation, and post-acute care performance.
Partner with operational teams to simplify processes, reduce unnecessary complexity, and improve consistency across review activities.
Promote the use of technology, standardized workflows, and data-driven decision-making to enhance operational effectiveness.
Regulatory Compliance and Review Standards
Ensure clinical review activities comply with applicable federal and state laws, CMS guidance, Medicare Advantage requirements, Medicaid requirements, Humana policies, and contractual obligations.
Support adherence to review policies, procedures, performance standards, and regulatory timelines.
Promote compliance-focused decision-making across clinical review and medical management activities.
Help ensure determinations are supported by appropriate documentation, clinical rationale, and evidence-based standards.
Identify and escalate regulatory, clinical, or operational concerns as appropriate.
Cross-Functional Collaboration
Partner with leaders and stakeholders across OneHome, Home Care Solutions, Medicare, Medicaid, Commercial, clinical operations, compliance, quality, and utilization management.
Collaborate with teams focused on provider engagement, member experience, care coordination, discharge planning, rehabilitation, and home care solutions operations.
Translate complex clinical, regulatory, and policy requirements into clear guidance for business and operational partners.
Participate in meetings, workgroups, and strategic initiatives to address clinical review needs, operational barriers, and performance improvement opportunities.
Build trusted relationships with internal partners to support shared accountability and successful OneHome execution.
Consumer Experience and Quality of Care
Support Humana’s commitment to continuously improving consumer experiences.
Promote appropriate access to clinically necessary services while maintaining compliance with regulatory and policy requirements.
Help reduce friction for members, providers, and internal partners through clear communication, timely decision-making, and consistent application of clinical standards.
Support care models that improve quality, coordination, and continuity across home-based and post-acute care settings.
Contribute to decisions and strategies that support better health outcomes and a more seamless healthcare experience.
Required Qualifications
Doctor of Medicine (MD/DO) degree from an accredited university in the USA
Current and ongoing board certification in an approved ABMS Medical Specialty
Active unrestricted license in at least one jurisdiction and willing to obtain additional licenses, as required, for various states in region of assignment
2+ years of project leadership experience
5+ years of direct clinical patient care experience post-residency or fellowship
No current sanction from Federal or State Governmental organizations and the ability to satisfy onboarding requirements
There are holiday and weekend requirements for this role
Excellent verbal and written communication skills with analytic and interpretative skills from prior experience focusing on quality, utilization, and/or case management
Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual
Sponsorship is not available for this role
Preferred Qualifications
Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
Internal Medicine, Family Practice, Geriatrics, OBGYN, Hospitalist clinical specialists
How We Value You
Interview Process
As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making through on-demand candidate assessments.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions. You should anticipate the assessment to take approximately 10-15 minutes.
Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.
SSN Task via Workday
Should you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.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.
$246,100 - $344,200 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Application Deadline: 08-30-2026
