Remote Corporate Medical Director - Grievances & Appeals

Humana Inc; Columbus (OH); Remote; USD 246,000 - 344,000; Full time

Job summary

Humana Inc. is seeking a Corporate Medical Director to provide clinical interpretation and independent judgments on appeals decisions across Medicare, Medicaid, and Commercial products.

This leadership role requires extensive medical expertise and the ability to collaborate with cross-functional teams to improve member experience and ensure compliant review processes. You will oversee grievance reviews, set policy interpretation, and serve as a clinical SME across home health, inpatient, and

Qualifications

• MD or DO degree.
• Unrestricted license in at least one jurisdiction.
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• Board Certified in an approved ABMS Medical Specialty.
• Prompt professional communication skills written and verbally.

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.
• Provide expertise across relevant clinical specialties such as Internal Medicine, Family Practice, Geriatrics, and Hospital Medicine.
• Support holiday or after-hours coverage as required to maintain regulatory and operational review timelines.
• Maintain awareness of emerging regulations, accreditation standards, and medical policy changes affecting grievance and appeal determinations.

Skills

Unrestricted license

Clinical judgment

Communication skills

Education

MD/DO degree

Board Certification

Job description

Humana Inc. is seeking a Corporate Medical Director to provide clinical interpretation and independent judgments on appeals decisions across Medicare, Medicaid, and Commercial products.

This leadership role requires extensive medical expertise and the ability to collaborate with cross-functional teams to improve member experience and ensure compliant review processes. You will oversee grievance reviews, set policy interpretation, and serve as a clinical SME across home health, inpatient, and