Remote Medical Director, Medicare Compliance

Humana, Inc.; Salt Lake City (UT); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana, Inc. in the United States seeks a Medical Director to lead reviews of services for Medicare and Medicaid members, ensuring alignment with CMS guidance and Humana policies.

This role emphasizes regulatory compliance and clinical decision-making across Home Health and related areas. The Medical Director evaluates medical necessity, coordinates with leadership, and participates in credentialing and educational activities, while managing timely reviews and maintaining high professional

Qualifications

• MD or DO degree.
• Current, active board certification from ABMS or AOABPS.
• Current and unrestricted state medical license in at least one state and willingness to obtain others.
• No sanctions from Federal or State Governmental organizations.
• 5 years of direct clinical patient care experience post residency or fellowship.
• Ability to pass credentialing requirements.
• Strong verbal and written communication skills.
• Adaptable and willing to learn new technologies to enhance workflow efficiency.

Responsibilities

• Review clinical cases and determine medical necessity of services for Medicare and Medicaid members.
• Ensure compliance with review policies, procedures, and regulatory standards.
• Apply CMS policies and Medicare/Medicare Advantage/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

Verbal and written communication

Microsoft Office proficiency

Internet navigation

Credentialing ability

Adaptable to new tech

Education

MD or DO degree

Board certification: ABMS/AOABPS

Active state medical license

Job description

Humana, Inc. in the United States seeks a Medical Director to lead reviews of services for Medicare and Medicaid members, ensuring alignment with CMS guidance and Humana policies.

This role emphasizes regulatory compliance and clinical decision-making across Home Health and related areas. The Medical Director evaluates medical necessity, coordinates with leadership, and participates in credentialing and educational activities, while managing timely reviews and maintaining high professional