Medical Director - Inpatient Review

Humana Inc; Santa Fe (NM); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. seeks a Medical Director to perform expert inpatient medical necessity reviews in collaboration with a multidisciplinary team.

You will analyze complex hospital cases, assess medical necessity against national guidelines, CMS regulations, and Humana policies, and provide clear utilization management determinations. Responsibilities include communicating outcomes to providers, maintaining high productivity and accuracy, and adapting to evolving workflows and systems.

Qualifications

• Minimum of 5 years post-residency clinical experience.
• Active, unrestricted medical license in at least one state; willingness to obtain more licenses.
• Board Certification in an AOABPS- or ABMS-recognized specialty; strong analytical and documentation skills.

Responsibilities

• Perform expert inpatient medical necessity reviews based on guidelines, CMS regulations, Humana policies, and clinical standards.
• Analyze complex hospital-based cases and deliver clear utilization management determinations.
• Communicate review outcomes with external providers via phone and in writing.
• Collaborate within a structured, team-oriented environment to support high-quality decision-making.

Skills

5+ years post-residency experience

Active medical license

Strong analytical and communication

Education

MD or DO

Board Certification AOABPS/ABMS

Active unrestricted license

Job description

Become a part of our caring community

The Medical Director relies on medical background and reviews health claims. 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.

Join a distinguished team of physicians dedicated to advancing the quality of inpatient care through clinical expertise and thoughtful medical necessity review. This position is well-suited for physicians who excel in case analysis, structured decision-making, and collaboration, offering an opportunity to impact patient outcomes without the physical demands or irregular hours of bedside care. Physicians with backgrounds in Hospital Medicine, Critical Care, Emergency Medicine, or those experienced in Utilization Review are encouraged to apply.

Role Overview

• Perform expert clinical review of inpatient medical records, assessing medical necessity based on national guidelines, CMS regulations, Humana policies, and recognized clinical standards.

• Analyze complex hospital-based cases and deliver clear, well-reasoned utilization management determinations.

• Communicate with external providers via phone to obtain clinical information and discuss review outcomes.

• Collaborate within a structured, team-oriented environment that emphasizes integrity, professionalism, and collegiality.

• Advance Humana’s mission by supporting high-quality, consistent decision-making and fostering strong physician partnerships.

Responsibilities

• Conduct inpatient medical necessity reviews promptly and in accordance with regulatory requirements.

• Uphold excellence in productivity, accuracy, quality, and timely completion of assigned tasks.

• Communicate review outcomes clearly and professionally in both verbal and written formats.

• Demonstrate flexibility and adaptability to changing workflows, tools, and utilization management procedures.

Use your skills to make an impact

Required Qualifications

• MD or DO

• 5 or more years post-residency clinical experience

• Active, unrestricted medical license in at least one state and willingness to obtain additional licenses as needed.

• Current and ongoing Board Certification in an AOABPS- or ABMS-recognized medical specialty.

• Meets all credentialing requirements, with no state or federal sanctions.

• Strong analytical, communication, and documentation skills.

• Ability to work effectively within a structured environment and as part of a multidisciplinary team.

Preferred Qualifications

• Inpatient exposure (hospitalist-level acuity, ED, ICU, or hospital-based FP/IM).

• Prior experience in utilization management or inpatient review (Medicare Advantage, Managed Medicaid, or Commercial lines of business).

• Familiarity with MCG® or InterQual® guidelines.

• Experience providing care for Medicare populations and working in hospitals, integrated delivery networks (IDN), or medical management organizations.

• Demonstrated adaptability to changes in workflow, regulatory requirements, or clinical systems.

• Proficiency with clinical technology platforms and a commitment to process improvement and innovation.

• Interest in contributing to educational content, team teaching, or professional development initiatives.

• Dedication to supporting consistent outcomes, exceptional consumer experiences, and a highly engaged team culture.

Additional Information

• Reports directly to a Lead Medical Director.

• Standard work hours are Monday through Friday 8am-5pm local time , with rotational weekend/holiday coverage (approx. 5 weekends per year).

• May participate in organizational committees or special project teams.

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.

$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.

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.