Remote Medical Director: Grievances & Appeals

Humana Inc; Lansing (MI); Remote; USD 246,000 - 344,000; Full time

Job summary

Humana Inc. seeks a Corporate Medical Director to review appeals and provide clinical interpretation. You will exercise independent judgment on highly complex issues and act as a SME across Medicare, Medicaid, and Commercial products.

Remote position in the USA with potential travel for training or meetings. Requires MD/DO, active license, and ABMS board certification with 5+ years post-residency experience. Competitive pay and benefits are described in the posting.

Qualifications

• MD or DO degree with an unrestricted license in at least one jurisdiction.
• Board certification in an ABMS medical specialty.
• 5 years of clinical experience post residency.
• Knowledge of managed care including Medicare, Medicaid and Commercial products.
• Strong written and verbal communication skills.

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

Communication skills

Regulatory understanding

Decision making

Education

MD or DO degree

Licensed to practice in at least one jurisdiction

Board Certified in an ABMS medical specialty

5 years of clinical experience post residency

Job description

Humana Inc. seeks a Corporate Medical Director to review appeals and provide clinical interpretation. You will exercise independent judgment on highly complex issues and act as a SME across Medicare, Medicaid, and Commercial products.

Remote position in the USA with potential travel for training or meetings. Requires MD/DO, active license, and ABMS board certification with 5+ years post-residency experience. Competitive pay and benefits are described in the posting.