Remote Medical Director: Utilization & Care Management

Humana Inc; Springfield (IL); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana Inc. seeks a Medical Director to provide medical interpretation and determinations for services in line with national guidelines, CMS requirements, and Humana policies.

You'll review complex clinical data, coordinate decisions with teams, and support care management in inpatient, outpatient, and post-acute environments. Remote position based in the United States; travel occasionally to Humana offices may be required.

Qualifications

• MD or DO license and ABMS/AOA board certification.
• 5+ years of direct clinical patient care after residency/fellowship.
• Unrestricted license in at least one jurisdiction; willingness to obtain more.
• No federal/state sanctions; able to pass credentialing.
• Experience with quality, utilization, case management and discharge planning.
• Knowledge of Medicare Advantage, Medicaid and commercial plans.

Responsibilities

• Provide medical interpretation and determinations per guidelines and policies.
• Collaborate with teams across Humana; support care management initiatives.
• Review clinical records and decide level of care and site of service.
• Participate in dispute/appeals reviews and project teams.
• Communicate decisions to internal associates and support credentialing.

Skills

Analytical skills

Interpretation skills

Conflict resolution

Communication with physicians

Collaboration

Education

MD or DO degree

Board Certification (ABMS/AOA)

Tools

MCG/InterQual

Job description

Humana Inc. seeks a Medical Director to provide medical interpretation and determinations for services in line with national guidelines, CMS requirements, and Humana policies.

You'll review complex clinical data, coordinate decisions with teams, and support care management in inpatient, outpatient, and post-acute environments. Remote position based in the United States; travel occasionally to Humana offices may be required.