Remote Medical Director – Utilization & Care Management

Humana Inc; Charleston (WV); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Medical benefits

Dental & Vision

401(k)

Paid time off

Life & disability insurance

Job summary

Humana Inc. is seeking a Medical Director to apply clinical judgment in authorizing services, ensuring compliance with CMS rules, Humana policies and clinical standards.

You will learn Medicare, Medicaid, and Medicare Advantage requirements and translate them into daily practice. You will review moderately complex cases, discuss determinations with physicians and teams, and support care management across inpatient, post-acute, and outpatient settings.

Qualifications

• MD or DO degree and active medical license
• 5+ years of direct clinical patient care post residency/fellowship in inpatient or outpatient settings
• Board certification in ABMS or AOA and ongoing
• Willing to obtain additional licenses as required
• Experience with quality, utilization, case management, discharge planning, and post-acute services
• Knowledge of Medicare Advantage, Medicaid, and commercial products
• Experience with national guidelines such as MCG or InterQual
• Specialties include internal medicine, family practice, geriatrics, hospitalist, or emergency medicine

Responsibilities

• Provide medical interpretation and determinations on whether services align with guidelines and policies
• Collaborate with teams and communicate decisions to associates
• Perform daily utilization management after mentored training
• Participate in dispute and appeals reviews
• Engage on project teams or organizational committees
• Discuss with physicians, nurses, and other groups to support priorities

Skills

MD/DO

5+ years clinical experience

Board Certification ABMS/AOA

Active medical license

Licensing flexibility

Utilization management

Medicare Advantage knowledge

InterQual/MCG knowledge

Specialties: IM, Family, Geriatrics, H

Job description

Humana Inc. is seeking a Medical Director to apply clinical judgment in authorizing services, ensuring compliance with CMS rules, Humana policies and clinical standards.

You will learn Medicare, Medicaid, and Medicare Advantage requirements and translate them into daily practice. You will review moderately complex cases, discuss determinations with physicians and teams, and support care management across inpatient, post-acute, and outpatient settings.