Medical Director, Outpatient Utilization & Care

Humana Inc; Carson City (NV); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana Inc. seeks a Medical Director to apply clinical expertise in reviewing complex outpatient cases and making coverage determinations to support quality and compliance.

The role involves collaboration with physicians and internal partners to advance value-based care, population health, and care management while maintaining utilization management standards.

This remote role includes occasional travel, a 40-hour work week, and a compensation range with bonus eligibility.

Qualifications

• MD/DO with 5+ years of direct clinical care post residency.
• Board certification in an ABMS medical specialty is required.
• Current unrestricted medical license in at least one jurisdiction.

Responsibilities

• Determine authorizations for services, level of care, and site of service.
• Perform medical necessity and coverage reviews per CMS guidelines and Humana policies.
• Review moderately to complex outpatient cases using clinical documentation to support decisions.
• Communicate utilization review outcomes to internal stakeholders and external physicians as needed.
• Collaborate with physicians and cross-functional teams to support care management and population health goals.
• Support coding practices, documentation, grievances/appeals processes, and outpatient service reviews.

Skills

Clinical judgment

Communication skills

Analytical skills

Education

MD or DO degree

ABMS board certification

Current medical license

Job description

Humana Inc. seeks a Medical Director to apply clinical expertise in reviewing complex outpatient cases and making coverage determinations to support quality and compliance.

The role involves collaboration with physicians and internal partners to advance value-based care, population health, and care management while maintaining utilization management standards.

This remote role includes occasional travel, a 40-hour work week, and a compensation range with bonus eligibility.