Remote Medical Director: Clinical Oversight & Utilization

Humana; United States; On-site; USD 223,800 - 313,100; Full time

Benefits offered by this job

Remote work

Job summary

Humana is seeking a Medical Director to provide medical interpretation and determinations on services for Medicare, Medicaid, and Medicare Advantage populations. You will review clinical records, ensure alignment with CMS requirements, and apply Humana policies in collaboration with multiple teams.

After mentored training, you will perform daily utilization management tasks, communicate decisions to internal associates, and participate in dispute or appeals reviews as required.

Qualifications

• MD or DO with board certification and licensure in at least one jurisdiction.
• 5+ years of direct clinical patient care in inpatient/outpatient settings.
• Experience with Medicare/Medicaid/Commercial products and medical management.
• Familiarity with national guidelines such as MCG or InterQual.
• Ability to work in a CMS/Humana regulatory environment and credentialing process.
• Experience collaborating with case managers and care teams on complex cases.

Responsibilities

• Provide medical interpretation and determinations for services in line with national guidelines and CMS rules.
• Collaborate with internal teams to support organizational priorities and quality improvement.
• Participate in mentored training before performing daily utilization management tasks.
• Communicate decisions to internal associates and participate in dispute/appeals processes when needed.

Skills

Clinical review

Utilization management

Regulatory compliance

Communication with physicians

Education

MD or DO degree

Job description

Humana is seeking a Medical Director to provide medical interpretation and determinations on services for Medicare, Medicaid, and Medicare Advantage populations. You will review clinical records, ensure alignment with CMS requirements, and apply Humana policies in collaboration with multiple teams.

After mentored training, you will perform daily utilization management tasks, communicate decisions to internal associates, and participate in dispute or appeals reviews as required.