TheLead Medical Directorprovides clinical and operational leadership for medical review activities supporting Home Health, Skilled Nursing Facility, Durable Medical Equipment, Medicare/Medicaid dual-eligible requests, and related home care solutions. Grounded in CMS Medicare guidance and applicable regulatory requirements, this role ensures consistent, timely, fair, compliant, and evidence-based medical necessity determinations for Medicare, Medicaid, and Dual Eligible populations.

Leadership and Team Operations

• Oversee daily operations of a team of Medical Directors conducting appeals and clinical case reviews for Medicare and Dual Eligible populations.

• Maintain Medical Director staffing schedules, including paid time off, weekend coverage, after-hours coverage, and call rotation planning.

• Lead regular team meetings and cross-functional meetings with internal stakeholders, operational partners, and leadership.

• Foster development of Medical Directors through coaching, collaboration, education, and non-case review activities.

• Support team engagement and promote a collaborative culture aligned with organizational excellence and Humana9s leadership expectations.

• Partner with the Director of Physician Leadership and other Lead Medical Directors to ensure consistency in processes, expectations, and performance.

Clinical Case Review and Medical Necessity Determinations

• Conduct clinical case reviews for approximately50%of the role9s responsibilities.

• Review Medicare, Medicaid, and Dual Eligible member cases to determine medical necessity and appropriateness of requested services.

• Evaluate requests related to home health, skilled nursing facility services, durable medical equipment, and other home-based care services.

• Provide clinical interpretation and medical decisions regarding services requested or provided by other healthcare professionals.

• Apply national clinical guidelines, CMS requirements, Humana policies, clinical standards, review procedures, and applicable contracts consistently.

• Identify and resolve complex clinical, technical, and operational issues that arise during case review or appeals processes.

Regulatory Compliance and Medicare Requirements

• Ensure timely completion of clinical reviews and appeals to meet Medicare regulatory requirements.

• Support compliance with CMS Medicare guidance, Medicare Advantage requirements, Medicaid requirements, and applicable federal and state laws.

• Promote consistency, accuracy, fairness, and timeliness in medical necessity determinations.

• Support team performance related to CMS Star measures, particularlyTimelinessandFairnessmeasures.

• Ensure all clinical review work is conducted within Humana9s and OneHome9s regulatory compliance framework.

Cross-Functional Partnership and OneHome Support

• Develop collaborative relationships with key partners across the Medicare Line of Business, Home Care Solutions, OneHome, internal operations teams, and leadership.

• Serve as a clinical leader and subject matter resource for OneHome activities.

• Help align medical review practices with OneHome9s operational model andHumana9s broader Medicare and home care strategy.

• Support implementation of processes that improve service delivery, member experience, provider collaboration, and operational efficiency.

• Participate in meetings with business, clinical, operational, and compliance partners to address performance, process, and clinical review needs.

Operational Improvement and Performance Management

• Identify opportunities to improve medical management operations, workflow efficiency, review consistency, and case turnaround times.

• Support process improvement efforts related to home health, skilled nursing facility, durable medical equipment, Medicare, Medicaid, and Dual Eligible requests.

• Analyze clinical information and operational data to identify trends, risks, performance gaps, and opportunities for improvement.

• Promote workflow efficiencies through effective use of technology, systems, and standardized review practices.

• Contribute to scalable solutions that support OneHome and the evolving needs of Medicare members.

Education, Communication, and Clinical Expertise

• Participate in required educational activities, clinical conferences, and internal learning forums.

• Create and present educational content based on clinical subject matter expertise.

• Communicate clearly and professionally with Medical Directors, operational partners, leadership, and other stakeholders.

• Translate complex clinical guidelines, CMS policies, and Medicare requirements into clear guidance for consistent decision-making.

• Support knowledge-sharing across the Medical Director team to strengthen clinical review quality and consistency.

Member and Consumer Experience

• Deliver clinical decisions that support appropriate care, regulatory compliance, and a positive consumer experience

• Promote fair, timely, and evidence-based decisions for Medicare, Medicaid, and Dual Eligible members

• Help reduce unnecessary complexity in the clinical review process for members, providers, and internal partners

• Support Humana9s commitment to improving access, quality, and coordination of home-based care solutions

Alignment to Humana Leadership Expectations

• Modeling customer-focused decision-making

• Simplifying complex clinical and operational processes

• Collaborating across teams and business functions

• Supporting bold, outcome-oriented improvements

• Anticipating operational needs associated with OneHome

• Promoting shared accountability across clinical, operational, and compliance teams

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 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, MCGor 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, Hospitalist clinical specialists, inpatient and/or care of a Medicare type population (disabled or >65 years of age)

• Previous Medicare, Medicaid, and/or Commercial experience

How We Value You

• Benefits starting day 1 of employment

• Competitive 401k match

• Generous Paid Time Off accrual

• Tuition Reimbursement

• Parental Leave

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.

Scheduled Weekly Hours

Pay Range

Description of Benefits