Remote Medical Director, Outpatient Medicare Utilization

Humana Inc; Cheyenne (WY); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Remote work flexibility

Job summary

Humana Inc. is seeking a Medical Director to review complex outpatient preauthorization cases, applying guidelines and CMS policies to guide coverage decisions. You will work with internal teams and external physicians to gather information and discuss determinations.

The role emphasizes value-based care, population health, and care management, with remote work options and occasional travel for training or meetings. Strong clinical judgment is essential.

Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care post-residency or fellowship.
• Current ABMS board certification.
• Active medical license in at least one jurisdiction.
• No current sanctions; able to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Strong analytical and interpretive skills.
• Willingness to learn, adapt to change, and innovate.

Responsibilities

• Determine authorization for requested services, level of care, and site of service.
• Perform medical necessity and coverage reviews in compliance with CMS requirements and Humana policies.
• Review moderately complex to complex outpatient clinical cases with evidence-based documentation.
• Evaluate services against national guidelines and internal policies.
• Prioritize daily case review workload to meet timelines.
• Communicate utilization review decisions to internal stakeholders.
• Collaborate with external physicians for information and peer-to-peer reviews.
• Contribute to care management activities and resource utilization.
• Provide input on coding practices and clinical documentation.
• Collaborate with cross-functional teams to support regional goals.
• Engage with physicians and providers in value-based care initiatives.

Skills

Clinical judgment

Communication skills

Analytical reasoning

Education

MD/DO degree

ABMS board certification

Medical license

Job description

Humana Inc. is seeking a Medical Director to review complex outpatient preauthorization cases, applying guidelines and CMS policies to guide coverage decisions. You will work with internal teams and external physicians to gather information and discuss determinations.

The role emphasizes value-based care, population health, and care management, with remote work options and occasional travel for training or meetings. Strong clinical judgment is essential.