Medical Director, Outpatient Utilization & Care

Humana Inc; Honolulu (HI); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. seeks a Medical Director to apply clinical judgment in reviewing complex outpatient cases and making coverage determinations. You will work remotely with internal teams and external physicians to support utilization management and care management initiatives.

The role focuses on value-based care, population health, and collaboration within a structured, compliant environment. Travel is occasional, with a 40-hour work week and standard hours.

Qualifications

• MD or DO degree required.
• 5+ years of direct clinical patient care, outpatient experience preferred.
• ABMS board certification in an approved specialty.
• Current unrestricted medical license and willingness to obtain additional licenses.
• No current sanctions and ability to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Strong analytical and interpretive skills for evaluating information.

Responsibilities

• Determine authorization for requested services, level of care, and site of service.
• Conduct medical necessity and coverage reviews per CMS and Humana policies.
• Review moderately to complex outpatient cases using clinical documentation.
• Ensure services align with national guidelines and internal policies.
• Manage daily case review workload to meet compliance timelines.
• Communicate utilization decisions to internal stakeholders.

Skills

Verbal communication

Written communication

Analytical reasoning

Decision making

Education

MD or DO degree

ABMS Board Certification

Medical license in at least one jurisdiction

Job description

Humana Inc. seeks a Medical Director to apply clinical judgment in reviewing complex outpatient cases and making coverage determinations. You will work remotely with internal teams and external physicians to support utilization management and care management initiatives.

The role focuses on value-based care, population health, and collaboration within a structured, compliant environment. Travel is occasional, with a 40-hour work week and standard hours.