Remote Medical Director: Medicare & Compliance

Humana; Phoenix (AZ); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Remote work at home

Travel opportunities for training

Job summary

Humana, Inc. is seeking a Medical Director to oversee medical necessity determinations for Medicare and Medicaid members, ensuring alignment with CMS guidance and Humana policies.

The role requires interpreting clinical guidelines and regulatory standards, with emphasis on timely, compliant decisions and collaboration across care teams. The position involves remote work, 40-hour weeks, and weekend/on-call coverage.

Qualifications

• Current, active state medical license in at least one state and willingness to obtain others as required.
• MD or DO degree with board certification from ABMS/AOABPS.
• 5 years of direct clinical patient care experience post residency/fellowship.

Responsibilities

• Review clinical cases and determine medical necessity of services for Medicare/Medicaid members.
• Ensure compliance with review policies and regulatory standards.
• Apply CMS policies, Medicare/Medicaid guidelines and related requirements.
• Identify opportunities for medical management operational improvements.
• Participate in call rotations, including weekend and after-hours coverage.
• Contribute to an engaged team culture and deliver exceptional experiences to members.
• Engage in educational activities by attending conferences and creating content.
• Support Home Solutions and other activities as assigned by OneHome leadership.

Skills

Verbal and written communication

Microsoft Office proficiency

Licensing in state(s)

Regulatory interpretation

Data interpretation

Education

MD or DO degree

ABMS/AOABPS board certification

Tools

Microsoft Office

Job description

Humana, Inc. is seeking a Medical Director to oversee medical necessity determinations for Medicare and Medicaid members, ensuring alignment with CMS guidance and Humana policies.

The role requires interpreting clinical guidelines and regulatory standards, with emphasis on timely, compliant decisions and collaboration across care teams. The position involves remote work, 40-hour weeks, and weekend/on-call coverage.