Remote Medical Director: Outpatient & Value-Based Care

Humana Inc; Montpelier (VT); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. is seeking a Medical Director for National Outpatient Medicare to review preauthorization requests for complex outpatient cases.

You will apply clinical judgment to determine coverage, level of care, and site of service, using CMS guidelines and Humana policies. You will collaborate with physicians, internal teams, and regional leaders to support value-based care, population health, and improved health outcomes, while ensuring compliance and high-quality utilization management

Qualifications

• MD or DO degree is required.
• Board certification in an ABMS specialty is required.
• Current and unrestricted medical license in at least one jurisdiction; additional license may be needed.

Responsibilities

• Determine authorization for services, level of care, and site of service.
• Conduct medical necessity and coverage reviews per CMS guidelines and Humana policies.
• Review complex outpatient cases using submitted clinical documentation for evidence-based determinations.
• Collaborate with external physicians for information and peer-to-peer reviews.
• Participate in care management activities to support quality outcomes and resource utilization.
• Provide input on coding practices and grievance/appeals processes as applicable.

Skills

Clinical judgment

Communication skills

Analytical thinking

Collaboration

Education

MD or DO degree

Board Certification ABMS

Active medical license

Job description

Humana Inc. is seeking a Medical Director for National Outpatient Medicare to review preauthorization requests for complex outpatient cases.

You will apply clinical judgment to determine coverage, level of care, and site of service, using CMS guidelines and Humana policies. You will collaborate with physicians, internal teams, and regional leaders to support value-based care, population health, and improved health outcomes, while ensuring compliance and high-quality utilization management