Remote Medical Director, Medicare & Medicaid Compliance

Humana, Inc.; Juneau (AK); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Remote work at home

Job summary

Humana, Inc. is seeking a Medical Director to oversee medical necessity determinations for Medicare and Medicaid members, ensuring alignment with CMS guidelines and Humana policies. You will evaluate services, review clinical cases, and maintain regulatory compliance across a remote environment.

The role requires board-certified physicians, active licenses, and 5+ years of direct clinical care. Expect 40-hour weeks, weekend call rotations, onboarding in EST, and travel to Humana offices as

Qualifications

• MD or DO degree and active medical licenses.
• Board certification from ABMS or AOABPS; NBPMAS not accepted.
• Active and unrestricted state medical license; willingness to obtain others as needed.
• No sanctions from federal or state agencies.
• 5 years of direct clinical patient care after residency/fellowship.
• Ability to pass credentialing requirements.
• Proficient with Microsoft Office and internet navigation.
• Strong verbal and written communication with data interpretation skills.
• Adaptable and quick to learn new technologies.

Responsibilities

• Review clinical cases and determine medical necessity for Medicare/Medicaid members.
• Ensure compliance with policies, procedures, and regulatory standards.
• Apply CMS policies and Medicare/Medicaid requirements.
• Identify opportunities for medical management operational improvements.
• Participate in call rotations, including weekends.
• Contribute to an engaged team culture and excellence.
• Deliver exceptional consumer experiences.
• Participate in educational activities by attending required conferences and presenting content.
• Support Home Solutions and other activities as assigned.

Skills

Verbal and written communication

Microsoft Office

Data interpretation

Adaptability to new technologies

Education

MD or DO degree

Tools

Microsoft Office

Job description

Humana, Inc. is seeking a Medical Director to oversee medical necessity determinations for Medicare and Medicaid members, ensuring alignment with CMS guidelines and Humana policies. You will evaluate services, review clinical cases, and maintain regulatory compliance across a remote environment.

The role requires board-certified physicians, active licenses, and 5+ years of direct clinical care. Expect 40-hour weeks, weekend call rotations, onboarding in EST, and travel to Humana offices as