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
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.
$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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Application Deadline: 07-29-2026
