Remote Medical Director: Utilization & Care Management

Humana, Inc.; Salem (OR); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana, Inc. is seeking a Medical Director to review health claims, determine authorization levels, and ensure compliance with national guidelines. This fully remote role serves across the contiguous United States with CST working hours and occasional travel for training.

You will rely on CMS policies, MCG/InterQual, and internal guidelines, mentor teams, and lead utilization management across inpatient and post-acute care settings.

Qualifications

• MD or DO degree with board certification in a medical specialty.
• Current Louisiana and Oklahoma licenses, with ability to obtain more.
• 5+ years of direct clinical patient care post residency or fellowship.
• Experience in inpatient or post-acute care settings preferred.

Responsibilities

• Make determinations on requested services and level of care per guidelines.
• Review submitted clinical records and determine authorization.
• Communicate decisions to internal teams and participate in care management.
• Apply CMS, Humana policies, and clinical standards in decisions.

Skills

Excellent verbal and written

Analytical interpretation skills

Collaborative / cross-functional

Regulatory and policy awareness

Education

MD or DO degree

Board Certification (ABMS Medical Specialty)

Active medical license in US (incl. LA/OK)

Job description

Humana, Inc. is seeking a Medical Director to review health claims, determine authorization levels, and ensure compliance with national guidelines. This fully remote role serves across the contiguous United States with CST working hours and occasional travel for training.

You will rely on CMS policies, MCG/InterQual, and internal guidelines, mentor teams, and lead utilization management across inpatient and post-acute care settings.