Remote Medical Director: Medicare/Medicaid Compliance

Humana, Inc.; Boston (MA); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Short/Long-term disability and life保险

Job summary

Humana, Inc. is seeking a Medical Director to review medical necessity for Medicare and Medicaid members, ensuring services align with CMS guidelines and Humana policies. The role emphasizes regulatory compliance, clinical guideline interpretation, and collaboration with OneHome leadership.

The position requires an MD/DO, board certification, active state license, and 5 years of clinical care after residency. Remote work is supported, with travel as needed.

Qualifications

• MD or DO degree required.
• Current active board certification from ABMS or AOABPS; NBPA S not accepted.
• Current and unrestricted state medical license; willingness to obtain other licenses as needed.
• No sanctions from federal or state governmental bodies.
• 5 years of direct clinical patient care post-residency/fellowship.
• Ability to pass credentialing requirements.
• Proficiency with Microsoft Office and Internet navigation.
• Strong verbal and written communication with data interpretation.
• Adaptable and willing 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 CMS policies, Medicare/Medicaid requirements and clinical guidelines.
• Identify opportunities for medical management operational improvements.
• participate in call rotations including weekends and after-hours.

Skills

MD/DO degree

Board certification (ABMS/AOABPS)

State medical license

No sanctions

Clinical experience 5 yrs post-resid/f

Credentialing

MS Office

Communication skills

Tech adaptability

Education

MD or DO degree

Board certification (ABMS/AOABPS)

Tools

Microsoft Office

Internet navigation

Job description

Humana, Inc. is seeking a Medical Director to review medical necessity for Medicare and Medicaid members, ensuring services align with CMS guidelines and Humana policies. The role emphasizes regulatory compliance, clinical guideline interpretation, and collaboration with OneHome leadership.

The position requires an MD/DO, board certification, active state license, and 5 years of clinical care after residency. Remote work is supported, with travel as needed.