Medical Director - Medicaid N. Central

Choosegreaterpeoria; Kentucky; Hybrid; USD 223,000 - 314,000; Full time

Job summary

Join a leading healthcare organization as a Medical Director, where you'll leverage your medical expertise to review health claims and ensure compliance with national and state guidelines. This role involves collaboration with healthcare providers, oversight of coding and documentation, and active participation in care management. Ideal candidates will have an MD or DO degree, board certification, and significant clinical experience. Enjoy a competitive salary and comprehensive benefits while making a positive impact on community health.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401(k)

Paid Time Off

Disability Insurance

Life Insurance

Qualifications

• 5+ years of clinical patient care experience post-residency or fellowship.
• Unrestricted license in KY or willingness to obtain it.

Responsibilities

• Review health claims and determine service alignment with guidelines.
• Communicate decisions internally and manage care discussions.

Skills

Communication

Quality Management

Utilization Management

Case Management

Education

MD or DO degree

Board Certification in an approved ABMS Medical Specialty

Job description

Become a part of our caring community and help us put health first

The Medical Director relies on their medical background to review health claims. The work involves addressing moderately complex to complex issues, requiring in-depth analysis of situations or data.
The Medical Director actively uses their medical expertise, experience, and judgment to determine whether requested services, levels of care, or sites of service should be authorized. All work is conducted within a regulatory compliance framework and is supported by diverse resources, including national clinical guidelines, state policies, CMS policies, clinical references, internal training, and other sources. Medical Directors will learn the Medicaid requirements for North Central region states (VA, KY, OH, IN, WI) and apply this knowledge daily.

The role includes reviewing clinical scenarios from outpatient, inpatient, or post-acute care settings via computer, examining submitted records, prioritizing tasks, communicating decisions internally, and participating in care management. It also involves discussions with external physicians, conflict resolution, and oversight of coding, documentation, grievances, appeals, and reviews for DME, genetic testing, etc.

Occasionally, Medical Directors may communicate with external healthcare providers and community groups to support regional priorities, focusing on collaborative relationships, value-based care, population health, and disease management.

Use your skills to make an impact

Responsibilities

The Medical Director provides medical interpretations and determines whether services align with national guidelines, state and CMS requirements, Humana policies, and contractual standards. They support team collaboration, work independently after training, and adhere to compliance timelines.

Required Qualifications

• MD or DO degree
• 5+ years of clinical patient care experience post-residency or fellowship, preferably in inpatient/outpatient settings or Medicaid populations
• Current Board Certification in an approved ABMS Medical Specialty
• Unrestricted license in KY or willingness to obtain it by start date; willingness to obtain additional licenses as needed (IN, OH, VA, WI)
• No sanctions from federal or state agencies and able to pass credentialing
• Excellent communication skills
• Experience in quality management, utilization management, case management, or post-acute services

Preferred Qualifications

• Knowledge of managed care, Medicare Advantage, Medicaid, or commercial insurance
• Utilization management experience in relevant organizations
• Experience with national guidelines like MCG or InterQual
• Specialties such as Internal Medicine, Family Practice, Geriatrics, Pediatrics, Hospitalist, Emergency Medicine
• Advanced degrees (MBA, MHA, MPH)
• Experience with public health, population health, analytics, and business metrics
• Experience with Substance Use Disorder populations and complex case management
• Reside in KY

Additional Information

Reports to the Lead Medical Director - North Central Medicaid Markets. Conducts utilization management for KY, OH, VA, WI, IN Medicaid populations and may support other markets. May participate in projects or committees. Occasional travel to Humana offices may be required.

Scheduled Weekly Hours

40

Pay Range

$223,800 - $313,100 annually, based on experience and location. Eligible for bonuses based on performance.

Description of Benefits

Humana offers comprehensive benefits including medical, dental, vision, 401(k), paid time off, disability, life insurance, and more.

Application Deadline: 07-31-2025

About us

Humana Inc. is committed to health and well-being, providing insurance and healthcare services to improve quality of life for diverse populations.

Equal Opportunity Employer

Humana does not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or veteran status, and promotes affirmative action in employment.