Remote Medical Director - Utilization & Care Management

Humana Inc; United States; Remote; USD 224,000 - 313,000; Full time

Job summary

Humana, Inc. seeks a Medical Director to interpret medical data and make determinations on services in alignment with national guidelines, CMS requirements, and Humana policies.

The role includes reviewing clinical records, discussing decisions with care teams, and supporting utilization management across Medicare, Medicaid, and commercial products. Reporting to the Lead Medical Director, the position is remote with 40 hours weekly, and may involve travel for training or meetings as needed,

Qualifications

• MD or DO degree required.
• Board Certification with ABMS or AOA.
• Current, unrestricted medical license in at least one jurisdiction.

Responsibilities

• Perform medical interpretation and determinations for services per guidelines.
• Collaborate with team and Humana colleagues.
• Review clinical records and participate in discussions for dispute and appeal decisions.

Skills

Analytic and interpretation skills

Utilization management

Discharge planning

Care management collaboration

Communication with physicians/nurses

Managed care knowledge

Education

MD or DO

Board Certification (ABMS/AOA)

Medical license (unrestricted)

Tools

InterQual

MCG guidelines

Job description

Humana, Inc. seeks a Medical Director to interpret medical data and make determinations on services in alignment with national guidelines, CMS requirements, and Humana policies.

The role includes reviewing clinical records, discussing decisions with care teams, and supporting utilization management across Medicare, Medicaid, and commercial products. Reporting to the Lead Medical Director, the position is remote with 40 hours weekly, and may involve travel for training or meetings as needed,