Medical Director - National Medicare Team

Humana; United States; Remote; USD 223,000 - 314,000; Full time

Job summary

Join a forward-thinking company as a Medical Director, where your expertise in clinical care can shape the future of healthcare services. In this pivotal role, you'll review preauthorization requests and ensure compliance with national guidelines while collaborating with a dedicated team. This remote position offers the chance to make a significant impact in the Medicare landscape, all while enjoying comprehensive benefits and a commitment to your professional growth. If you're looking to leverage your medical knowledge in a dynamic environment, this opportunity is for you!

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401(k)

Paid Time Off

Disability Insurance

Life Insurance

Qualifications

• 5+ years of clinical experience, preferably with Medicare populations.
• Current Board Certification and unrestricted medical license required.

Responsibilities

• Provide medical interpretation and compliance determinations.
• Collaborate with departments to support organizational objectives.

Skills

Verbal Communication

Written Communication

Analytical Skills

Interpretative Skills

Flexibility

Curiosity

Education

MD or DO degree

Board Certification in Medical Specialty

Advanced degrees (MBA, MHA, MPH)

Job description

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

The Medical Director relies on a medical background and reviews preauthorization requests for services. The role involves addressing moderately complex to complex issues requiring in-depth analysis of situations or data.

The Medical Director for the National Medicare Outpatient Team provides medical interpretation and makes determinations on whether services provided by healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and contracts. The primary responsibilities include reviewing prior-authorization requests, as well as some claims and provider dispute cases related to outpatient services.

Use your skills to make an impact

Responsibilities

• Provide medical interpretation and determinations regarding compliance with national guidelines, CMS requirements, Humana policies, and clinical standards.
• Collaborate with team members, other departments, and colleagues to support organizational objectives.
• Complete mentored training with minimal supervision and work independently thereafter.
• Maintain consistency in thinking and documentation, exercise independence, and meet compliance deadlines.
• Support market-wide objectives and community relations as directed.
• Participate in project teams or organizational committees.
• Report to a Lead Medical Director.

Required Qualifications

• MD or DO degree.
• 5+ years of clinical patient care experience post-residency or fellowship, preferably including inpatient experience and/or care of Medicare populations (disabled or >65 years).
• Current and ongoing Board Certification in an approved ABMS Medical Specialty.
• Unrestricted license in at least one jurisdiction, with willingness to obtain additional licenses if required.
• No current sanctions from governmental organizations and able to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Strong analytical and interpretative skills.
• Curiosity, flexibility, and innovation.

Preferred Qualifications

• Knowledge of managed care, Medicare Advantage, Medicaid, or Commercial products.
• Specialty in Medical Hematology/Oncology preferred.
• Experience with Medicaid, utilization management, and national guidelines such as NCD/LCD, MCG, or InterQual.
• Advanced degrees like MBA, MHA, MPH are a plus.
• Experience in quality or utilization management teams.

Additional Information

Reports to a Lead Medical Director. Conducts utilization management for assigned markets and populations. May participate in project teams or committees.

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

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 through insurance and healthcare services, aiming to improve quality of life for diverse populations.

Equal Opportunity Employer

Humana values diversity and inclusion, adhering to policies that prohibit discrimination and promote affirmative action.