Remote Medical Director - Medicare & Regulatory Compliance

Humana, Inc.; Atlanta (GA); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus eligible

Job summary

Humana, Inc. is seeking a Medical Director to oversee the medical necessity decisions for Medicare and Medicaid members, ensuring alignment with CMS and Humana policies. The role involves reviewing clinical cases, maintaining regulatory compliance, and working within defined timelines.

The position requires MD or DO with active board certification and medical licensure across states in the region. Remote work is supported, with occasional travel for training or meetings as needed.

Qualifications

• MD or DO degree and active medical licensure requested.
• Board certification from ABMS/AOABPS required; NBPA S certification not accepted.
• Ability to obtain licenses as required for multiple states in the region.
• Strong communication skills and data interpretation abilities.
• Experience meeting credentialing requirements and regulatory standards.

Responsibilities

• Review clinical cases and determine medical necessity for Medicare and Medicaid members.
• Ensure compliance with review policies, procedures, and regulatory standards.
• Apply CMS policies, Medicare requirements, and clinical guidelines to decisions.
• Identify opportunities for medical management operational improvements.
• Participate in call rotations, including weekends and after-hours coverage.
• Contribute to a collaborative team culture and deliver exceptional consumer experiences.
• Attend required conferences and create content for subject matter contributions.
• Support Home Solutions and other activities as assigned by leadership.

Skills

Strong communication

Verbal and written communication

Analytical interpretation of data

Adaptable to new technologies

Education

MD or DO degree

Tools

Microsoft Office

Internet navigation

Job description

Humana, Inc. is seeking a Medical Director to oversee the medical necessity decisions for Medicare and Medicaid members, ensuring alignment with CMS and Humana policies. The role involves reviewing clinical cases, maintaining regulatory compliance, and working within defined timelines.

The position requires MD or DO with active board certification and medical licensure across states in the region. Remote work is supported, with occasional travel for training or meetings as needed.