Remote Medical Director: Medicare & Utilization Expert

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

Job summary

Humana, Inc. is seeking a Medical Director to review clinical data and determine service authorization based on national guidelines and CMS requirements. The role emphasizes collaboration with regional teams and mentoring before independent work.

The position focuses on inpatient and post-acute care contexts, with involvement in utilization management, quality improvement, and potential grievance/appeals activities, all within a remote US setting.

Qualifications

• MD or DO degree and board certification required.
• Current Louisiana and Oklahoma licenses, or ability to obtain others.
• Ability to work with CMS guidelines and quality measures.

Responsibilities

• Provide medical interpretation and determinations against national guidelines and CMS requirements.
• Collaborate with team members and regional colleagues; transition to independent work after mentoring.
• Support utilization management and Bold Goal objectives across markets.
• Participate in grievance and appeals reviews as appropriate.
• Communicate decisions to internal associates and external providers.

Skills

Verbal & written communication

Analytic interpretation

Team collaboration

Conflict resolution

Education

MD or DO degree

ABMS board certification

Medical licenses (LA & OK)

Job description

Humana, Inc. is seeking a Medical Director to review clinical data and determine service authorization based on national guidelines and CMS requirements. The role emphasizes collaboration with regional teams and mentoring before independent work.

The position focuses on inpatient and post-acute care contexts, with involvement in utilization management, quality improvement, and potential grievance/appeals activities, all within a remote US setting.