Remote Medical Director – Medicare & Compliance

Humana, Inc.; Dover (DE); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Remote work at home

Job summary

Humana, Inc. is seeking a Medical Director to ensure medical necessity of services for Medicare and Medicaid members and to align decision making with CMS policies, national guidelines, and Humana standards.

The role relies on interpreting clinical guidelines and applying them consistently within a framework of regulatory compliance. Travel may be required; remote work is supported with a 40-hour week and EST onboarding.

Qualifications

• MD or DO degree required.
• Board certification by ABMS or AOABPS required.
• Current and unrestricted state medical license.
• 5 years of direct clinical patient care experience.
• Ability to pass credentialing requirements.
• Proficient in Microsoft Office and internet navigation.
• Strong written and verbal communication skills.
• Willingness to learn new technologies.

Responsibilities

• Review clinical cases and determine medical necessity for Medicare and 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 coverage and after-hours coverage.
• Contribute to an engaged, collaborative team culture that supports organizational excellence.
• Deliver exceptional consumer experiences.
• Participate in educational activities by attending required conferences and creating content to present for individual subject matter contribution.
• Support Home Solutions and other activities as assigned by the OneHome leadership.

Skills

Clinical decision making

Regulatory interpretation

Communication skills

Adaptability

Education

MD or DO degree

Board certification ABMS/AOABPS

State medical license

Tools

Microsoft Office

Job description

Humana, Inc. is seeking a Medical Director to ensure medical necessity of services for Medicare and Medicaid members and to align decision making with CMS policies, national guidelines, and Humana standards.

The role relies on interpreting clinical guidelines and applying them consistently within a framework of regulatory compliance. Travel may be required; remote work is supported with a 40-hour week and EST onboarding.