Remote Medical Director – Utilization & Care Management

Humana Inc; Harrisburg (Dauphin County); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana Inc. is seeking a Medical Director to perform clinical determinations on requested services, guided by national guidelines and CMS requirements. You will review records, discuss decisions with internal teams, and participate in care management initiatives across inpatient, outpatient, and post-acute settings.

The role emphasizes collaboration, regulatory compliance, and utilization management with opportunities to contribute to dispute and appeals reviews. A mentoring program is provided.

Qualifications

• MD or DO degree required and board certified in a recognized specialty.
• Active, unrestricted medical license in at least one jurisdiction; willingness to obtain more.
• 5+ years of direct clinical patient care post residency or fellowship.
• Familiar with Medicare Advantage, Medicaid, and commercial products.
• Experience in quality, utilization, case management and discharge planning.

Responsibilities

• Provide medical interpretation and determinations against national guidelines and CMS requirements.
• Collaborate with internal teams and Humana colleagues to support priorities.
• After mentored training, perform daily medical review work.
• Support dispute and appeals reviews when needed.
• Engage with case managers on complex care management scenarios.

Skills

Clinical judgement

Analytic skills

Utilization management

Discharge planning

Care management

Team collaboration

Communication with physicians

Education

MD or DO

Board Certification (ABMS/AOA)

Medical license (active)

Tools

MCG

InterQual

Job description

Humana Inc. is seeking a Medical Director to perform clinical determinations on requested services, guided by national guidelines and CMS requirements. You will review records, discuss decisions with internal teams, and participate in care management initiatives across inpatient, outpatient, and post-acute settings.

The role emphasizes collaboration, regulatory compliance, and utilization management with opportunities to contribute to dispute and appeals reviews. A mentoring program is provided.