Corporate MD Grievance & Appeals

Humana Inc; United States; Remote; USD 246,000 - 344,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Disability and life insurance

Job summary

Humana Inc. seeks a Corporate Medical Director to lead medical interpretation and complex review determinations for appeals across Medicare, Medicaid, and Commercial lines. This fully remote leadership role requires board certification, a valid medical license, and extensive clinical experience.

You will collaborate with cross-functional teams to improve timeliness, compliance, and member-centered outcomes, supporting home health and hospital-based review processes.

Qualifications

• MD or DO degree required.
• Active, unrestricted license in at least one state.
• Board certification in an approved ABMS specialty.
• Minimum of 5 years' clinical experience post-residency.

Responsibilities

• Review medical records for appeals decisions and provide clinical interpretation.
• Determine appropriateness and necessity of services per policy and performance standards.
• Oversee grievance and appeal reviews for assigned markets and populations.
• Serve as clinical SME for Medicare, Medicaid and Commercial products.

Skills

Clinical judgment

Communication skills

Managed care knowledge

Education

MD or DO degree

Current unrestricted license in at least one jurisdiction

Board Certified in an ABMS Medical Specialty

Job description

Corporate Medical Director

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-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.

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.

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

$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

• 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

Application Deadline

10-13-2026

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.