Remote Medical Director - Medicare & CMS Compliance

Humana Inc; Boise (ID); On-site; USD 224,000 - 313,000; Full time

Benefits offered by this job

Remote work at home

40-hour work week

Bonus incentive plan

Job summary

Humana Inc. seeks a Medical Director to oversee medical necessity determinations for Medicare/Medicaid members, ensuring alignment with CMS guidelines, Humana policies, and contractual requirements.

All work occurs within a regulated framework to maintain compliance with federal and state laws. Responsibilities include reviewing cases, supporting regulatory reviews, and contributing to medical management improvements while coordinating with OneHome leadership and participating in ongoing

Qualifications

• MD or DO degree required and board-certified.
• Active medical license in at least one state; willingness to obtain others as needed.
• Board certification by ABMS or AOABPS; NBPPAS not accepted; strong CMS/Medicare knowledge.
• Ability to pass credentialing requirements and undergo regulatory checks.

Responsibilities

• Review clinical cases and determine medical necessity for Medicare/Medicaid members.
• Ensure compliance with review policies, procedures, and regulatory standards.
• Apply clinical guidelines, CMS policies, and Medicare/Medicaid requirements.
• Identify opportunities for medical management operational improvements.
• Participate in call rotations, including weekend and after-hours coverage.
• Contribute to a collaborative team culture and drive organizational excellence.
• Deliver exceptional consumer experiences.
• Attend required conferences and create content for subject matter contributions.
• Support Home Solutions and other activities as assigned by OneHome leadership.

Skills

Microsoft Office

Internet navigation

Verbal and written communication

Analytical skills

Education

MD or DO degree

ABMS/AOABPS board certification

Active medical license in at least one state

Tools

Credentialing software

Job description

Humana Inc. seeks a Medical Director to oversee medical necessity determinations for Medicare/Medicaid members, ensuring alignment with CMS guidelines, Humana policies, and contractual requirements.

All work occurs within a regulated framework to maintain compliance with federal and state laws. Responsibilities include reviewing cases, supporting regulatory reviews, and contributing to medical management improvements while coordinating with OneHome leadership and participating in ongoing