Remote Medical Director, Grievance & Appeals Expert

Humana Inc; Phoenix (AZ); Remote; USD 246,000 - 344,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Job summary

Humana Inc. is seeking a Corporate Medical Director to provide clinical interpretation and independent judgment on the appropriateness of services across Medicare, Medicaid, and Commercial products.

This remote role requires robust clinical experience and ABMS board certification, with travel for training as needed. The candidate will oversee grievance and appeal reviews, ensure regulatory compliance, and collaborate with cross-functional teams to improve member outcomes and operational

Qualifications

• MD or DO degree.
• Current and unrestricted license in at least one jurisdiction; willing to obtain license without conditions.
• No current sanction from Federal or State Governmental organizations; able to pass credentialing.
• Board Certified in an ABMS medical specialty.
• Prompt professional communication skills (written and verbal).
• 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 or conditions.
• Ensure determinations comply with policies, regulatory requirements and standards.
• Serve as a clinical subject matter expert for complex grievance and appeal matters across Medicare, Medicaid, and Commercial products.
• Make independent decisions on highly complex clinical issues.

Skills

Clinical interpretation

Independent judgment

Managed care knowledge

Professional communication

Regulatory awareness

Education

MD or DO degree

ABMS Board Certification

Job description

Humana Inc. is seeking a Corporate Medical Director to provide clinical interpretation and independent judgment on the appropriateness of services across Medicare, Medicaid, and Commercial products.

This remote role requires robust clinical experience and ABMS board certification, with travel for training as needed. The candidate will oversee grievance and appeal reviews, ensure regulatory compliance, and collaborate with cross-functional teams to improve member outcomes and operational