Remote Medical Director, Outpatient Utilization & Care

Humana Inc; Boise (ID); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Remote work option

Occasional travel

Job summary

Humana Inc. is seeking a Medical Director to review complex outpatient Medicare cases, determine coverage and site of service, and ensure compliance with CMS guidelines. The role involves evidence-based decision-making, collaboration with physicians, and contributing to value-based care initiatives.

You will work in a structured environment, driving utilization management and care coordination while supporting regional goals and stakeholder engagement.

Qualifications

• MD or DO degree required.
• Board certification in an ABMS specialty.
• Active/unrestricted medical license in at least one jurisdiction.
• No current sanctions and able to meet credentialing requirements.

Responsibilities

• Determine authorization for services, level of care, and site of service.
• Perform medical necessity and coverage reviews per CMS and Humana policies.
• Review moderately to complex outpatient cases using clinical documentation.
• Evaluate alignment with national guidelines and internal policies.
• Prioritize daily case review workload to meet turnaround times.
• Communicate utilization decisions to internal stakeholders.
• Collaborate with external physicians for information and peer reviews.
• Support care management activities to improve outcomes.
• Provide input on coding practices, documentation, and appeals.

Skills

Excellent communication skills

Analytical and interpretive skills

Independent work

Collaboration with physicians

Education

MD or DO degree

Board Certification in ABMS specialty

Unrestricted medical license

No sanctions/credentialing readiness

Job description

Humana Inc. is seeking a Medical Director to review complex outpatient Medicare cases, determine coverage and site of service, and ensure compliance with CMS guidelines. The role involves evidence-based decision-making, collaboration with physicians, and contributing to value-based care initiatives.

You will work in a structured environment, driving utilization management and care coordination while supporting regional goals and stakeholder engagement.