Remote Medical Director, Medicare & Medicaid Compliance

Humana, Inc.; Frankfort (KY); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Remote work at home

40-hour work week

Possible travel for training

Job summary

Humana, Inc. is seeking a Medical Director to oversee and align Home Health, SNF, DME, and related Medicare/Medicaid services with CMS guidelines, Humana policies, and contracts.

The role emphasizes medical necessity reviews, regulatory compliance, and collaboration with the OneHome leadership to drive patient-centered care. Responsibilities include reviewing cases, ensuring policy compliance, and applying CMS and Medicare requirements.

Qualifications

• MD or DO degree required.
• Active board certification from ABMS or AOABPS; NBPAS not accepted.
• Current and unrestricted state medical license; willingness to obtain licenses as region requires.
• No sanctions from federal or state government.
• At least 5 years of direct clinical patient care after residency or fellowship.
• Ability to pass credentialing requirements.
• Intermediate to advanced skills with Microsoft Office and Internet navigation.
• Strong verbal and written communication; ability to analyze data clearly.
• Adaptable and willing to learn new technologies to enhance workflow.

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 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 subject matter contribution.
• Support Home Solutions and other activities as assigned by OneHome leadership.

Skills

Verbal and written communication

Microsoft Office

Internet navigation

Education

MD or DO degree

Active medical license

Tools

ABMS/AOABPS board certification

Job description

Humana, Inc. is seeking a Medical Director to oversee and align Home Health, SNF, DME, and related Medicare/Medicaid services with CMS guidelines, Humana policies, and contracts.

The role emphasizes medical necessity reviews, regulatory compliance, and collaboration with the OneHome leadership to drive patient-centered care. Responsibilities include reviewing cases, ensuring policy compliance, and applying CMS and Medicare requirements.