Remote Medical Director, Grievances & Appeals

Humana; United States; 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

Disability and life insurance

Job summary

Humana is seeking a Corporate Medical Director to provide clinical interpretation and independent determinations for grievance and appeal cases across Medicare, Medicaid, and Commercial products. The role demands medical expertise, regulatory acumen, and leadership in a fully remote US-based environment.

Ideal candidates hold an MD/DO, board certification, active license in at least one state, and 5+ years of post-residency experience.

Qualifications

• MD or DO degree and current unrestricted license in at least one jurisdiction.
• Board Certified in an approved ABMS Medical Specialty.
• 5 years of established clinical experience post residency.
• Knowledge of the managed care industry including Medicare, Medicaid and/or Commercial products.
• Willing to obtain licensure for region of assignment as needed.
• Strong written and verbal communication skills.

Responsibilities

• Provide clinical interpretation and determinations on service appropriateness and quality.
• Oversee clinical reviews of grievance and appeal cases for assigned markets.
• Ensure determinations comply with medical review policies, regulatory requirements, 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 with incomplete information or competing factors.
• Act as a clinical resource for issues involving home health, rehabilitation, inpatient, outpatient, and transitional care services.
• Ensure grievance reviews reflect knowledge of managed care operations and related 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 escalations.
• Provide expertise across clinical specialties such as Internal Medicine, Family Practice, Geriatrics, and Hospital Medicine.
• Support holiday or after-hours coverage to maintain regulatory and operational timelines.
• Maintain awareness of regulatory/accreditation changes affecting grievance and appeal determinations.

Skills

Clinical judgment

Communication skills

Medical policy knowledge

Regulatory compliance

Cross-functional collaboration

Decision making

Home health knowledge

Remote work readiness

Education

MD or DO degree

Job description

Humana is seeking a Corporate Medical Director to provide clinical interpretation and independent determinations for grievance and appeal cases across Medicare, Medicaid, and Commercial products. The role demands medical expertise, regulatory acumen, and leadership in a fully remote US-based environment.

Ideal candidates hold an MD/DO, board certification, active license in at least one state, and 5+ years of post-residency experience.