Medical Director - National Medicare Team

Humana; Juneau (AK); Remote; USD 223,000 - 314,000; Full time

Job summary

An established industry player seeks a dedicated Medical Director to join their National Medicare Outpatient Team. This pivotal role involves reviewing preauthorization requests and ensuring compliance with national guidelines and clinical standards. The ideal candidate will possess a strong medical background, excellent communication skills, and a passion for patient care. Enjoy a structured work environment while making a significant impact on the quality of care provided to Medicare patients. This opportunity offers competitive compensation, a supportive team, and a chance to innovate in healthcare delivery.

Benefits

Medical Benefits

Dental Benefits

Vision Benefits

401(k) Retirement Savings Plan

Paid Time Off

Short-term and Long-term Disability

Life Insurance

Qualifications

• 5+ years of direct clinical patient care experience post residency or fellowship.
• Current and unrestricted license in at least one jurisdiction.

Responsibilities

• Provides medical interpretation and determinations for healthcare services.
• Supports collaboration with team members and meets compliance timelines.

Skills

Verbal Communication

Analytical Skills

Flexibility

Curiosity to Learn

Education

MD or DO degree

Board Certification in an approved ABMS Medical Specialty

Advanced degree (MBA, MHA, MPH)

Job description

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

The Medical Director relies on medical background and reviews preauthorization requests for services. 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.

The Medical Director for the National Medicare Outpatient Team provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. Primary work reviewing prior-authorization reviews as well as some claims and provider dispute cases for outpatient reviews.

Use your skills to make an impact

Responsibilities

The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies and clinical standards. The ideal candidate supports and collaborates with other team members, other departments and Humana colleagues. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations, and meets compliance timelines. Supports the assigned work with respect to market-wide objectives and community relations as directed. May participate on project teams or organizational committees. Reports to a Lead Medical Director.

Required Qualifications

• MD or DO degree

• 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age).

• Current and ongoing Board Certification in an approved ABMS Medical Specialty

• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required.

• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.

• Excellent verbal and written communication skills.

• Evidence of analytic and interpretation skills

• The curiosity to learn, the flexibility to adapt and the courage to innovate.

Preferred Qualifications

• Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.

• Prefer Medical Hematology/Oncology specialties

• Prefer Medicaid experience

• Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance.

• Experience with national guidelines such as NCD/LCD, MCG or InterQual.

• Advanced degree such as an MBA, MHA, MPH

• Prior experience participating in teams focusing on quality management or utilization management.

Additional Information

Reports to a Lead Medical Director. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May participate on project teams or organizational committees.

#physiciancareers

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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 07-31-2025

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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.