Remote Medical Director, Outpatient Utilization ValueBased

Humana Inc; Austin (TX); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus eligibility

Remote work with travel

Job summary

Humana Inc. is seeking a Medical Director to oversee outpatient Medicare case reviews, determining coverage and level of care with clinical judgment and evidence-based standards. You will coordinate with physicians, manage complex determinations, and contribute to care management initiatives to improve outcomes.

The role emphasizes value-based care, population health, and collaboration with internal partners to ensure compliant utilization management and high-quality service delivery.

Qualifications

• MD or DO degree and ABMS board certification.
• 5+ years of direct clinical care, preferably outpatient or Medicare-related.
• Current unrestricted medical license and credentialing eligibility.
• Excellent verbal and written communication, professional and responsive.
• Strong analytical skills and sound clinical judgment with adaptable mindset.

Responsibilities

• Review requests for services, level of care, and site of service for outpatient cases.
• Conduct medical necessity and coverage reviews per CMS and Humana policies.
• Perform computer-based review of moderately to complex cases with clinical documentation.
• Evaluate alignment with national guidelines and internal policies.
• Prioritize daily caseloads to meet turnaround times and compliance timelines.
• Communicate decisions and collaborate with external physicians for peer reviews.
• Engage in care management activities to support quality outcomes and resource use.
• Provide input on coding practices and grievance/appeals processes when applicable.
• Collaborate with regional leadership to support market goals and value-based care.

Skills

Clinical judgment

Medical necessity reviews

Communication skills

Analytical skills

Outpatient care experience

Education

MD/DO degree

Tools

CMS guidelines

Medicare policies

Utilization management systems

Job description

Humana Inc. is seeking a Medical Director to oversee outpatient Medicare case reviews, determining coverage and level of care with clinical judgment and evidence-based standards. You will coordinate with physicians, manage complex determinations, and contribute to care management initiatives to improve outcomes.

The role emphasizes value-based care, population health, and collaboration with internal partners to ensure compliant utilization management and high-quality service delivery.