Remote Medical Director - Utilization & Care Management

Humana Inc; Tallahassee (FL); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Medical benefits

401(k) plan

Paid time off

Job summary

Humana Inc. is seeking a Medical Director to determine service authorization based on national guidelines, CMS requirements, and Humana policies.

You will review complex clinical scenarios, discuss determinations with internal teams, and participate in care management and appeals processes. You will engage with physicians and nurses, support organizational priorities, and contribute to population health goals while adhering to regulatory standards.

Qualifications

• MD or DO degree required.
• Board Certification in an approved specialty.
• Active license in at least one jurisdiction and willingness to obtain additional licenses.
• Experience with quality/utilization/case management and post-acute services.

Responsibilities

• Provide medical interpretation and determinations on service authorization.
• Review submitted clinical records and determine level of care.
• Collaborate with internal teams and Humana colleagues.
• Participate in care management, discharge planning, and post-acute services discussions.

Skills

Analytical skills

Interpretation skills

Team collaboration

Communication with physicians/nurses

Quality Utilization management

Education

MD or DO

Board Certification (ABMS/AOA)

Tools

MCG/InterQual guidelines

Job description

Humana Inc. is seeking a Medical Director to determine service authorization based on national guidelines, CMS requirements, and Humana policies.

You will review complex clinical scenarios, discuss determinations with internal teams, and participate in care management and appeals processes. You will engage with physicians and nurses, support organizational priorities, and contribute to population health goals while adhering to regulatory standards.