Medical Director, Outpatient Medicare (Remote)

Humana; Saint Paul (MN); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Remote work possible

Job summary

Humana is seeking a Medical Director to review complex outpatient cases, determine authorizations, and support utilization management. You will apply clinical guidelines and CMS policies to guide decisions, collaborate with physicians, and contribute to value-based care.

This remote role requires MD/DO, board certification, and at least 5 years of clinical experience; licensure in one or more jurisdictions and willingness to obtain additional licenses.

Qualifications

• MD or DO degree is required.
• 5 years of direct clinical patient care experience post residency or fellowship, preferably outpatient or Medicare-related.
• Board Certification in an ABMS medical specialty.
• Current unrestricted license and ability to obtain additional licenses.
• Excellent verbal and written communication, strong analytical skills.

Responsibilities

• Determine authorization for requested services, level of care, and site of service.
• Perform medical necessity and coverage reviews per CMS and Humana policies.
• Review moderately complex to complex outpatient cases using clinical documentation.
• Collaborate with external physicians for additional information and peer-to-peer reviews.
• Contribute to care management activities and utilization management.

Skills

Clinical judgment

Analytical skills

Communication skills

Adaptability

Collaboration

Education

MD or DO degree

Job description

Humana is seeking a Medical Director to review complex outpatient cases, determine authorizations, and support utilization management. You will apply clinical guidelines and CMS policies to guide decisions, collaborate with physicians, and contribute to value-based care.

This remote role requires MD/DO, board certification, and at least 5 years of clinical experience; licensure in one or more jurisdictions and willingness to obtain additional licenses.