Remote Medical Director: Utilization & Care Quality

Humana Inc; Montpelier (VT); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana Inc. is seeking a Medical Director to oversee utilization management, determine service appropriateness, and ensure compliance with national guidelines and CMS requirements.

The role emphasizes collaboration with clinicians and interdisciplinary teams across inpatient, outpatient, and post-acute settings. Ideal candidates have 5+ years of direct clinical care, board certification, and a valid medical license.

Qualifications

• MD/DO with board certification and medical licensure.
• 5+ years of direct clinical patient care post residency/fellowship.
• Experience with utilization management and case management.
• Knowledge of Medicare Advantage, Medicaid, and commercial products.
• Familiarity with national guidelines such as MCG or InterQual.
• Specialties: Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine.

Responsibilities

• Provide medical interpretation and determinations on services per national guidelines, CMS requirements, and Humana policies.
• Collaborate with teammates and departments; communicate decisions to internal associates.
• After mentored training, perform daily utilization management work and related duties.
• Support dispute and appeals processes when applicable.
• Engage in project teams or organizational committees as needed.

Skills

Clinical decision making

Utilization management

Medicare/Medicaid knowledge

Communication with physicians

Team collaboration

Education

MD/DO degree

Board Certification (ABMS/AOA)

Job description

Humana Inc. is seeking a Medical Director to oversee utilization management, determine service appropriateness, and ensure compliance with national guidelines and CMS requirements.

The role emphasizes collaboration with clinicians and interdisciplinary teams across inpatient, outpatient, and post-acute settings. Ideal candidates have 5+ years of direct clinical care, board certification, and a valid medical license.