Remote Medical Director: Utilization & Care Management

Humana Inc; Cheyenne (WY); On-site; USD 224,000 - 313,000; Full time

Benefits offered by this job

Remote work in United States

Bonus incentive plan

Travel opportunities

Job summary

Humana Inc. seeks a Medical Director to lead utilization management and perform medical determinations for Medicare-related services in a fully remote US role. The position emphasizes coding interpretation, clinical documentation, and collaboration with care management and regional leaders.

Ideal candidates hold an MD/DO with 5+ years of clinical care, board certification, and active licensure. Travel is occasional, with strong emphasis on regulatory compliance and stakeholder communication.

Qualifications

• MD or DO degree required.
• 5+ years of direct clinical patient care post-residency or fellowship, including inpatient exposure or Medicare-type population experience.
• Current and ongoing Board Certification in an ABMS medical specialty.
• Active, unrestricted license in at least one jurisdiction (willing to obtain more if needed).
• No current sanctions; able to pass credentialing requirements.
• Professional, prompt verbal and written communication skills.
• Experience with quality management, utilization management, case management or related post-acute services.

Responsibilities

• Review health claims and clinical documents to evaluate moderately complex to complex cases.
• Determine medical necessity and authorize services, level of care, and site of service.
• Conduct computer-based reviews of inpatient and post-acute clinical scenarios.
• Assess records against national guidelines, CMS policies, and internal policies.
• Apply Medicare/Medicare Advantage requirements in utilization decisions.
• Prioritize daily case reviews and communicate determinations to stakehholders.
• Engage with external physicians to obtain information and discuss plans.
• Use professional judgment and conflict-resolution skills for complex determinations.
• Ensure services align with clinical standards, regulatory requirements, and contracts.
• Support grievance/appeals reviews and, in some roles, oversight of coding and documentation.
• Collaborate with care management, regional leadership, and Humana departments to ensure compliance and priorities.
• Build relationships with contracted physicians, facilities, and partners to support value-based care.

Skills

Analytical skills

Clinical judgment

Verbal & written communication

Team collaboration

Education

MD or DO degree

Job description

Humana Inc. seeks a Medical Director to lead utilization management and perform medical determinations for Medicare-related services in a fully remote US role. The position emphasizes coding interpretation, clinical documentation, and collaboration with care management and regional leaders.

Ideal candidates hold an MD/DO with 5+ years of clinical care, board certification, and active licensure. Travel is occasional, with strong emphasis on regulatory compliance and stakeholder communication.