Remote Medical Director: Medicare & Medicaid Compliance

Humana; Boise (ID); Remote; 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 CMS Medicare guidance on Home Health, SNF, DME, and related services for Medicare/Medicaid members.

The role focuses on medical necessity, regulatory compliance, and clinical guideline interpretation, working within OneHome’s governance framework. Responsibilities include credentialing, policy interpretation, and cross-functional collaboration to improve care management, with remote work and fixed 40-hour weeks plus after-hours coverage.

Qualifications

• MD or DO degree and board certification from ABMS or AOABPS.
• Active state medical license and ability to obtain others as needed.
• Experience with credentialing processes and regulatory standards.
• Strong communication and data analysis abilities.

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

Verbal and written communication

Analytical skills

Regulatory compliance adaptability

Microsoft Office proficiency

Education

MD or DO degree

ABMS/AOABPS board certification

Active medical license in at least one state

Credentialing pass capability

Tools

Microsoft Office

Internet navigation

Job description

Humana, Inc. seeks a Medical Director to oversee CMS Medicare guidance on Home Health, SNF, DME, and related services for Medicare/Medicaid members.

The role focuses on medical necessity, regulatory compliance, and clinical guideline interpretation, working within OneHome’s governance framework. Responsibilities include credentialing, policy interpretation, and cross-functional collaboration to improve care management, with remote work and fixed 40-hour weeks plus after-hours coverage.