Remote Medical Director - Inpatient Utilization Review

Humana; United States; Remote; USD 180,000 - 260,000; Full time

Job summary

Humana is seeking a Medical Director to lead expert clinical reviews of inpatient records, ensuring medical necessity aligns with national guidelines and CMS regulations. The role emphasizes thoughtful decision-making, collaboration with physicians, and high-quality utilization review across complex cases.

Flexible remote work within the contiguous US is offered, with standard hours and periodic on-call coverage.

Qualifications

• MD or DO degree and active license in at least one state with willingness to obtain additional licenses as needed.
• Board certification in AOABPS- or ABMS-recognized specialty.
• 5+ years post-residency clinical experience in relevant inpatient settings.
• Strong analytical, communication, and documentation skills.

Responsibilities

• Perform expert clinical review of inpatient medical records to assess medical necessity per guidelines, CMS regulations, Humana policies, and clinical standards.
• Analyze complex hospital-based cases and deliver clear utilization management determinations.
• Communicate review outcomes with external providers by phone and in written formats.
• Collaborate within a structured, team-oriented environment to support quality, consistent decision-making and physician partnerships.

Skills

Analytical thinking

Communication

Documentation

Team collaboration

Education

MD or DO

Job description

Humana is seeking a Medical Director to lead expert clinical reviews of inpatient records, ensuring medical necessity aligns with national guidelines and CMS regulations. The role emphasizes thoughtful decision-making, collaboration with physicians, and high-quality utilization review across complex cases.

Flexible remote work within the contiguous US is offered, with standard hours and periodic on-call coverage.