Remote Medical Director - Inpatient Utilization & Compliance

Humana Inc; San Juan (PR); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. is seeking a Medical Director to apply medical judgment for inpatient authorization decisions, guided by national guidelines and CMS rules. You’ll review complex cases, coordinate with teams, and maintain compliance across programs including Medicare and Medicaid.

After mentored training, you’ll perform with independence, support market goals, and may discuss cases with external providers. A mix of inpatient and post-acute experience is valued for this leadership role.

Qualifications

• MD or DO degree with ABMS board certification.
• Active medical license in at least one jurisdiction.
• 5+ years of direct clinical patient care, inpatient preferred.
• No current sanctions from federal or state authorities.
• Excellent verbal and written communication skills.
• Experience in quality, utilization, case management or post-acute services.

Responsibilities

• Provide medical interpretation and determinations per guidelines and policies.
• Collaborate with team and Lead Medical Director; mentored training completion.
• Operate with independence to meet departmental expectations and timelines.
• Support market-wide objectives and community relations as directed.
• Engage in disputes, grievances and appeals reviews when needed.

Skills

Verbal and written communication

Analytic interpretation

Team collaboration

Regulatory and compliance mindset

Quality/utilization management

Education

MD or DO degree

ABMS board certification

Medical license in at least one jurisdiction

No sanctions on record

Job description

Humana Inc. is seeking a Medical Director to apply medical judgment for inpatient authorization decisions, guided by national guidelines and CMS rules. You’ll review complex cases, coordinate with teams, and maintain compliance across programs including Medicare and Medicaid.

After mentored training, you’ll perform with independence, support market goals, and may discuss cases with external providers. A mix of inpatient and post-acute experience is valued for this leadership role.