Medical Director — Remote Utilization & Care Governance

Humana; United States; Remote; USD 224,000 - 313,000; Full time

Job summary

Humana is seeking a Medical Director to lead utilization decisions for complex clinical scenarios and ensure compliance with national guidelines and CMS requirements. You will review records, interpret data, and collaborate with health services leadership to optimize care decisions.

The role requires an MD/DO with board certification, a current license, and 5+ years of clinical experience, including post-residency inpatient exposure.

Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care experience post residency or fellowship.
• Current and ongoing Board Certification in an approved ABMS Medical Specialty.
• A current and unrestricted license in at least one jurisdiction.
• No current sanction from Federal or State Governmental organizations, and able to pass onboarding requirements.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills, with experience in quality/utilization/care management.

Responsibilities

• Provide medical interpretation and clinical determinations regarding service alignment with guidelines and CMS requirements.
• Review clinical information and apply evidence-based criteria for compliant decisions.
• Collaborate with cross-functional teams to support objectives.
• Perform daily work with mentorship and then independence.
• Communicate determinations clearly to internal and external stakeholders.
• Demonstrate professionalism and accountability in line with Humana’s objectives.

Skills

Clinical decision making

Communication skills

Leadership

Analytical thinking

Education

MD or DO

Job description

Humana is seeking a Medical Director to lead utilization decisions for complex clinical scenarios and ensure compliance with national guidelines and CMS requirements. You will review records, interpret data, and collaborate with health services leadership to optimize care decisions.

The role requires an MD/DO with board certification, a current license, and 5+ years of clinical experience, including post-residency inpatient exposure.