Remote Medical Director: Utilization & Care Management

Humana Inc; Baton Rouge (LA); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. is seeking a Medical Director to apply their medical background and clinical judgment to authorize services, assess level of care, and determine site of service within regulatory guidelines.

The role involves review of complex clinical scenarios, assessment of records, and collaboration with physicians, nurses, and internal teams in a remote setting. After mentored training, you will perform daily utilization management and participate in care management activities.

Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care post-residency or fellowship.
• Current and ongoing ABMS or AOA board certification.
• Current and unrestricted license in at least one jurisdiction; willing to obtain additional licenses.
• No current sanctions; able to pass credentialing requirements.
• Analytic and interpretation skills; experience with quality/utilization/case management and post‑acute services.
• Knowledge of the managed care industry including Medicare Advantage, Medicaid, Commercial products, or related structures.
• Utilization management experience in a medical management organization (e.g., Medicare Advantage, Managed Medicaid, or Commercial health insurance).
• Experience with national guidelines such as MCG or InterQual.
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, and Emergency Medicine specialists.

Responsibilities

• Provide medical interpretation and determinations of services against national guidelines, CMS requirements, Humana policies, and clinical standards.
• Collaborate with other teams, departments, and Humana colleagues.
• After mentored training, perform daily utilization management work.
• Discuss cases with physicians, nurses, and internal groups to support priorities.
• Contribute to quality management, population health, and care management initiatives.

Skills

MD/DO

Clinical experience

Board Certification

Medical license

Credentialing

Analytic skills

Managed care knowledge

Utilization management

InterQual knowledge

Clinical specialties

Education

MD/DO

Board Certification

Job description

Humana Inc. is seeking a Medical Director to apply their medical background and clinical judgment to authorize services, assess level of care, and determine site of service within regulatory guidelines.

The role involves review of complex clinical scenarios, assessment of records, and collaboration with physicians, nurses, and internal teams in a remote setting. After mentored training, you will perform daily utilization management and participate in care management activities.