Remote Medical Director — Utilization & Care Management

Humana, Inc.; Helena (MT); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana, Inc. is seeking a Medical Director to leverage medical expertise in reviewing health claims and determining authorization for services, guided by CMS and Humana policies.

The role focuses on complex clinical determinations, with exposure to inpatient/post-acute care settings. Remote within the contiguous US, with standard 8am-5pm CST hours, 40-hour weeks, and potential travel for training or meetings.

Qualifications

• MD or DO degree required with clinical experience post-residency/fellowship.
• Board Certification in an approved ABMS Medical Specialty.
• Active medical licenses (Louisiana and Oklahoma) or ability to obtain.
• Evidence of analytics/interpretation skills and experience in quality/utilization management.

Responsibilities

• Provide medical interpretation and determinations aligned with national guidelines and CMS requirements.
• Collaborate with team, Humana colleagues and regional leadership to guide decisions.
• Perform utilization management and participate in grievance/appeals when applicable.
• Engage with care management teams and external physicians as needed.

Skills

MD/DO clinician

Board Certification

Medical Licenses (LA, OK)

Inpatient care experience

Utilization Management

Communication skills

Education

MD or DO degree

Board Certification (ABMS)

Active licenses: LA & OK

Job description

Humana, Inc. is seeking a Medical Director to leverage medical expertise in reviewing health claims and determining authorization for services, guided by CMS and Humana policies.

The role focuses on complex clinical determinations, with exposure to inpatient/post-acute care settings. Remote within the contiguous US, with standard 8am-5pm CST hours, 40-hour weeks, and potential travel for training or meetings.