Corporate MD Grievance & Appeals

Humana Inc; Dover; Remote; GBP 184,000 - 258,000; Full time

Benefits offered by this job

Medical benefits

401(k) plan

Paid time off

Bonus incentive plan

Job summary

Humana, Inc. is seeking a Corporate Medical Director who provides clinical interpretation and determinations on the appropriateness of services delivered by healthcare professionals.

The role involves independent judgment on complex reviews and supports grievance and appeal processes across Medicare, Medicaid, and Commercial lines of business. The position requires MD or DO with an unrestricted license, ABMS board certification, and at least 5 years of post-residency clinical experience.

Qualifications

• MD or DO degree and current unrestricted license in at least one jurisdiction
• Board certification in an approved ABMS medical specialty
• 5 years of established clinical experience post residency
• Strong written and verbal communication skills
• Knowledge of managed care including Medicare, Medicaid and commercial products

Responsibilities

• Provide medical interpretation and clinical judgment on appropriateness, necessity, and quality of services.
• Perform or oversee clinical reviews of grievance and appeal cases.
• Ensure all determinations comply with medical review policies and regulatory requirements.
• Serve as clinical subject matter expert for complex grievance and appeal matters across lines of business.
• Make independent decisions on highly complex clinical issues with incomplete information.
• Act as a clinical resource for home health, rehab, inpatient, outpatient, and transitional care services.
• Ensure reviews reflect knowledge of managed care operations.
• Partner with cross-functional teams to improve consistency, turnaround times, and member-centered decisions.
• Contribute to initiatives to enhance member experience and reduce escalations.
• Provide expertise across Internal Medicine, Family Practice, Geriatrics, Hospital Medicine.
• Support holiday or after-hours coverage to maintain timelines.
• Maintain awareness of regulations and medical policy changes.

Skills

Independent judgment

Critical thinking

Cross-functional collaboration

Communication skills

Education

MD/DO degree

Unrestricted license

Board Certified

5 years clinical experience

Job description

Become a part of our caring community

The Corporate Medical Director relies on medical background and reviews of medical records for appeals decisions. The Corporate Medical Director works on problems of diverse scope and complexity ranging from moderate to substantial.

The Corporate Medical Director provides clinical interpretation and makes determinations regarding the appropriateness of services delivered by other healthcare professionals, in accordance with established review policies, procedures, and performance standards. The Corporate Medical Director exercises independent judgment in addressing complex issues related to job responsibilities and associated tasks, applying critical analysis to variable factors and determining the most appropriate course of action.

• Provide medical interpretation and clinical judgment regarding the appropriateness, necessity, and quality of services rendered by other healthcare professionals.
• Perform or oversee clinical reviews of grievance and appeal cases for assigned markets, member populations, or condition-specific areas.
• Ensure all determinations are made in compliance with medical review policies, regulatory requirements, internal procedures, and performance standards.
• Serve as a clinical subject matter expert for complex grievance and appeal matters involving Medicare, Medicaid, and Commercial products.
• Make independent decisions on highly complex clinical issues , including cases with variable factors, incomplete information, or competing clinical considerations.
• Act as a clinical resource for issues involving home health, rehabilitation, inpatient, outpatient, and transitional care services .
• Ensure appeal and grievance reviews reflect knowledge of managed care operations , including Medicare, Medicaid, and Commercial line-of-buisness requirements .
• Partner with cross-functional teams to improve consistency, turnaround times, compliance, and member-centered decision-making .
• Contribute to initiatives focused on improving the member experience and reducing preventable escalations or dissatisfaction.
• Provide expertise across relevant clinical specialties such as Internal Medicine, Family Practice, Geriatrics, and Hospital Medicine .
• Support holiday or after-hours coverage as required to maintain regulatory and operational review timelines .
• Maintain awareness of emerging regulations, accreditation standards, and medical policy changes affecting grievance and appeal determinations.

Use your skills to make an impact

Required Qualifications

• MD or DO degree
• A current and unrestricted license in at least one jurisdiction, able and willing to obtain a license without conditions , as required, for various states in region of assignment
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• Board Certified in an approved ABMS Medical Specialty
• Prompt professional communication skills written and verbally
• 5 years of established clinical experience post residency
• Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Medical utilization management experience in MA Grievances and Appeals
• Working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, Anesthesiology, Physical Medicine and Rehabilitation, Emergency Medicine, Neurology, and General Surgery clinical specialists

Work Style

Fully remote living in the USA. Occasional travel to Humana's offices for training or meetings may be required.

Work Hours

Typical business hours are Monday-Friday, 8 hours/day, 5 days/week-- some flexibility might be possible, depending on business needs. Holidays and weekends as required by needs of the business.

Very minimal travel might be required for training, meetings, and/or conferences

Interview Format

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 with 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.

This is a remote position

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: 10-29-2026

About us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.