Remote Medical Director, Utilization & Compliance

Humana Inc; Sacramento (CA); Remote; USD 224,000 - 313,000; Full time

Benefits offered by this job

Bonus incentive plan

Remote work

Travel opportunities

Job summary

Humana Inc. is seeking a Medical Director for a remote role focused on determining service appropriateness per national guidelines, CMS requirements, and Humana policies.

The role involves reviewing clinical records, discussing decisions with physicians and internal teams, and participating in care management initiatives. Post- residency experience and board certification are required, with licensure in at least one jurisdiction.

Qualifications

• MD or DO degree required.
• 5+ years direct clinical patient care after residency/fellowship.
• Board Certification in an ABMS or AOA specialty.
• Current and unrestricted license in at least one jurisdiction; willingness to obtain more licenses.
• Experience with quality/utilization/case management and post-acute services.
• Knowledge of Medicare Advantage, Medicaid, and commercial products.

Responsibilities

• Provide medical interpretation and determinations on services per guidelines and policies.
• Collaborate with team members and other departments; participate in mentored training before independent work.
• Discuss determinations with physicians, nurses, and internal groups to support organizational priorities.
• Contribute to dispute and appeals reviews when applicable.

Skills

MD/DO patient care

5+ years clinical experience

Board certification

Medical license

CMS/Medicare knowledge

Utilization management

Education

MD or DO degree

Job description

Humana Inc. is seeking a Medical Director for a remote role focused on determining service appropriateness per national guidelines, CMS requirements, and Humana policies.

The role involves reviewing clinical records, discussing decisions with physicians and internal teams, and participating in care management initiatives. Post- residency experience and board certification are required, with licensure in at least one jurisdiction.