Remote Medical Director, Grievances & 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

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.