Remote Medical Director, Outpatient Utilization

Humana Inc; Helena (MT); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. is seeking a Medical Director to review complex outpatient preauthorization requests, make coverage determinations, and support high-quality utilization management.

The role emphasizes collaboration with physicians and cross-functional teams to advance value-based care and population health initiatives. The position offers a remote-friendly environment with travel as needed, requiring MD/DO credentials, ABMS board certification, and an unrestricted license.

Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care after residency or fellowship.
• Current ABMS Board Certification.
• Active license in at least one jurisdiction and willingness to obtain more.
• No current sanctions and able to pass credentialing.

Responsibilities

• Determine authorization for requested services, level of care, and site of service.
• Perform medical necessity and coverage reviews per CMS, Humana policies, and clinical criteria.
• Review moderately to complex outpatient cases with documentation to support determinations.
• Collaborate with external physicians for additional information and peer-to-peer reviews.
• Contribute to care management activities and input on coding and documentation.

Skills

Analytical skills

Verbal & written communication

Team collaboration

Adaptability

Decision making

Education

MD or DO degree

ABMS Board Certification

Licensed in at least one jurisdiction

Job description

Humana Inc. is seeking a Medical Director to review complex outpatient preauthorization requests, make coverage determinations, and support high-quality utilization management.

The role emphasizes collaboration with physicians and cross-functional teams to advance value-based care and population health initiatives. The position offers a remote-friendly environment with travel as needed, requiring MD/DO credentials, ABMS board certification, and an unrestricted license.