Remote Medical Director — Claims & Utilization

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

Job summary

Humana is seeking a Medical Director - Claims to lead medical determinations in line with national guidelines, CMS requirements, and Humana policies. You will interpret clinical data, review records, and authorize services across inpatient, outpatient, and post-acute settings, with mentored training to full autonomy.

The role emphasizes utilization management, quality improvement, and collaboration with case managers and care teams.

Qualifications

• MD or DO degree required.
• 5+ years of direct clinical patient care experience post residency or fellowship.
• Current and ongoing Board Certification an approved ABMS or AOA Medical Specialty.
• Current and unrestricted license in at least one jurisdiction and willingness to obtain additional licenses.
• No current sanction from Federal or State Governmental organizations, and ability to pass credentialing requirements.
• Experience with managed care, utilization management, and medical management reviews.

Responsibilities

• Provide medical interpretation and determinations whether services align with national guidelines, CMS requirements, Humana policies, and clinical standards.
• Collaborate with team members and other departments; participate in mentored training before performing daily work.
• Lead Utilization Management across assigned market, population, or condition type; contribute to dispute and appeals reviews.
• Engage in project teams or organizational committees as needed.

Skills

Clinical judgement

Regulatory knowledge

Utilization management

Medicare/Medicaid knowledge

Analytical skills

Education

MD or DO degree

Tools

InterQual guidelines

MCG guidelines

Job description

Humana is seeking a Medical Director - Claims to lead medical determinations in line with national guidelines, CMS requirements, and Humana policies. You will interpret clinical data, review records, and authorize services across inpatient, outpatient, and post-acute settings, with mentored training to full autonomy.

The role emphasizes utilization management, quality improvement, and collaboration with case managers and care teams.