The Medical Director is responsible for Medicaid care strategy and/or operations. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
Responsibilities:
Uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and assisted by diverse resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources
Learns Medicaid requirements and understands how to operationalize this knowledge in their daily work in their assigned cluster
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, with clinical scenarios arising from outpatient or inpatient environments
Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process, and in some instances, these may require conflict resolution skills
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 and a focus on collaborative business relationships, value-based care, population health, or disease or care management
Supports Humana values and our enterprise social needs team mission throughout all activities
Flows to work as needed within cluster as needed for vacations, weekends and holidays coverage
Use your skills to make an impact
Qualifications:
Doctor of Medicine or Doctor of Osteopathy
Board-certified in ABMS or ABPN recognized specialty
A current and unrestricted license in at least one of the states that are part of the specific cluster, and ability to obtain licenses in the other cluster states that require licensure.
Able to satisfy onboarding requirements
At least five years of experience post-training providing clinical services
Experience in utilization management review and case management in a health plan setting
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting
Experience with accreditation process (NCQA)
Experience with CGX and MHK
Has licensure through the Interstate Medical Licensure Compact
Preferred:
Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting
Experience in utilization management review and case management in a health plan setting
Experience with accreditation process (NCQA)
Experience with CGX and MHK
Has licensure through the Interstate Medical Licensure Compact
Reporting Relationship:
This position reports directly to the Cluster Lead Medical Director.
Location:
This role is based virtually in one of the states of the specific cluster, which includes: IN, OH, KY, VA, WI, & IL
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees9 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: 08-20-2026
