Remote Medical Director: Medicare & Compliance

Humana; Santa Fe (NM); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

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

The role involves review of services, regulatory compliance, and collaboration with leadership to drive operational improvements. Remote work is available with a 40-hour schedule, including call rotations and after-hours coverage.

Qualifications

• MD or DO degree.
• Board certification from ABMS or AOABPS.
• Current and unrestricted state license, with ability to obtain other licenses as required.
• 5 years of direct clinical patient care experience post residency/fellowship.
• Ability to pass credentialing requirements.
• Proficiency in Microsoft Office and Internet navigation; strong communication skills.
• Adaptable and quick to learn new technologies.

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 clinical guidelines, 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

Communication skills

Clinical expertise

Microsoft Office

Data interpretation

Education

MD or DO degree

Tools

Microsoft Office

Internet navigation

Job description

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

The role involves review of services, regulatory compliance, and collaboration with leadership to drive operational improvements. Remote work is available with a 40-hour schedule, including call rotations and after-hours coverage.