Remote Corporate Medical Director – Grievance & Appeals

Humana Inc; Olympia (WA); Remote; USD 246,000 - 344,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement plan

Paid time off and holidays

Disability insurance

Life insurance

Job summary

Humana Inc. is seeking a Corporate Medical Director to provide clinical interpretation and lead grievance/appeal reviews across Medicare, Medicaid, and Commercial lines.

You will apply independent judgment on highly complex cases and support cross-functional teams to improve timelines and member outcomes. Required are an MD or DO, a current unrestricted license, board certification, and 5+ years of clinical experience post residency.

Qualifications

• MD or DO degree.
• Unrestricted license in at least one jurisdiction, able and willing to obtain licenses as required.
• Board Certified in an ABMS medical specialty.
• 5 years of established clinical experience post residency.
• Knowledge of the managed care industry including Medicare, Medicaid and Commercial products.

Responsibilities

• Provide medical interpretation and clinical judgment regarding the appropriateness, necessity, and quality of services rendered by other healthcare professionals.
• Perform or oversee clinical reviews of grievance and appeal cases for assigned markets, member populations, or condition-specific areas.
• Ensure all determinations are made in compliance with medical review policies, regulatory requirements, internal procedures, and performance standards.
• Serve as a clinical subject matter expert for complex grievance and appeal matters involving Medicare, Medicaid, and Commercial products.
• Make independent decisions on highly complex clinical issues, including cases with variable factors, incomplete information, or competing clinical considerations.
• Act as a clinical resource for issues involving home health, rehabilitation, inpatient, outpatient, and transitional care services.
• Ensure appeal and grievance reviews reflect knowledge of managed care operations, including Medicare, Medicaid, and Commercial line-of-business requirements.
• Partner with cross-functional teams to improve consistency, turnaround times, compliance, and member-centered decision-making.
• Contribute to initiatives focused on improving the member experience and reducing preventable escalations or dissatisfaction.

Skills

Communication skills

5 years clinical experience

Managed care knowledge

Consumer experience focus

State licensing readiness

Education

MD or DO degree

Job description

Humana Inc. is seeking a Corporate Medical Director to provide clinical interpretation and lead grievance/appeal reviews across Medicare, Medicaid, and Commercial lines.

You will apply independent judgment on highly complex cases and support cross-functional teams to improve timelines and member outcomes. Required are an MD or DO, a current unrestricted license, board certification, and 5+ years of clinical experience post residency.