Remote Medical Director - Medicare & Utilization Oversight

Humana Inc; Nashville (TN); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. is seeking a Medical Director to review inpatient and post-acute requests, determine authorization levels, and ensure compliance with national guidelines, CMS rules, and Humana policies.

The role involves analysis of complex clinical records, mentoring, and collaboration with internal teams. This is a remote position with occasional travel to Humana offices for training or meetings; requires MD or DO, board certification, and at least five years of direct clinical experience,

Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care post residency.
• Current and ongoing Board Certification an approved ABMS Medical Specialty.
• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license.
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation.

Responsibilities

• Medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and contracts.
• Collaborate with team members, other departments, Humana colleagues and the Lead Medical Director.
• After mentored training, perform daily work with minimal direction.
• Support market-wide objectives and community relations as directed.
• May engage in disputes, grievance and appeals reviews.

Skills

Verbal communication

Written communication

Analytical skills

Team collaboration

Education

MD/DO degree

Board Certification

Job description

Humana Inc. is seeking a Medical Director to review inpatient and post-acute requests, determine authorization levels, and ensure compliance with national guidelines, CMS rules, and Humana policies.

The role involves analysis of complex clinical records, mentoring, and collaboration with internal teams. This is a remote position with occasional travel to Humana offices for training or meetings; requires MD or DO, board certification, and at least five years of direct clinical experience,