Corporate MD Grievance & Appeals

Humana; United States; Remote; USD 180,000 - 260,000; Full time

Job summary

Humana is seeking a Corporate Medical Director to provide clinical interpretation and approve the appropriateness of services across grievance and appeal cases. This remote role supports multiple markets and requires independent judgment on complex clinical issues.

You will collaborate with cross-functional teams to apply rigorous medical review policies, stay current with regulatory changes, and drive payer-specific requirements to improve member experience across Humana’s diverse population.

Qualifications

• MD or DO with unrestricted license in at least one jurisdiction.
• 5 years of clinical experience post residency.
• Knowledge of managed care industry including Medicare, Medicaid and/or Commercial products.
• Prompt professional communication skills written and verbally.
• Willingness to obtain licenses as required for states in region of assignment.
• Pass credentialing requirements and maintain regulatory standards.

Responsibilities

• Provide medical interpretation and clinical judgement 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 comply with medical review policies, regulatory requirements, internal procedures, and performance standards.
• Serve as a clinical SME for complex grievance and appeal matters involving Medicare, Medicaid, and Commercial products.
• Make independent decisions on highly complex clinical issues with variable factors and incomplete information.
• 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 and payer 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 escalations.
• Provide expertise across Internal Medicine, Family Practice, Geriatrics, Hospital Medicine as needed.
• Support after-hours coverage to maintain regulatory and operational timelines.

Skills

Clinical judgment

Regulatory knowledge

Communication skills

Credentialing

Managed care knowledge

Education

MD or DO degree

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 judgement 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-business 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' abil