[Hiring] Corporate Medical Director Grievance & Appeals @Humana

Role Description

Become a part of our caring community. The Corporate Medical Director relies on medical background and reviews of medical records for appeals decisions. The Corporate Medical Director works on problems of diverse scope and complexity ranging from moderate to substantial.

• Provide medical interpretation and clinical judgment regarding the appropriateness, necessity, and quality of services rendered by other healthcare professionals.
• Perform or oversee clinical reviews of grievance and appeal cases for assigned markets, member populations, or condition-specific areas.
• Ensure all determinations are made in compliance with medical review policies, regulatory requirements, internal procedures, and performance standards.
• Serve as a clinical subject matter expert for complex grievance and appeal matters involving Medicare, Medicaid, and Commercial products.
• Make independent decisions on highly complex clinical issues, including cases with variable factors, incomplete information, or competing clinical considerations.
• Act as a clinical resource for issues involving home health, rehabilitation, inpatient, outpatient, and transitional care services.
• Ensure appeal and grievance reviews reflect knowledge of managed care operations, including Medicare, Medicaid, and Commercial line-of-business requirements.
• Partner with cross-functional teams to improve consistency, turnaround times, compliance, and member-centered decision-making.
• Contribute to initiatives focused on improving the member experience and reducing preventable escalations or dissatisfaction.
• Provide expertise across relevant clinical specialties such as Internal Medicine, Family Practice, Geriatrics, and Hospital Medicine.
• Support holidays and weekends as required based on business needs. After-hours coverage as required to maintain regulatory and operational review timelines.
• Maintain awareness of emerging regulations, accreditation standards, and medical policy changes affecting grievance and appeal determinations.

Qualifications

• MD or DO degree
• Current, unrestricted licensure in at least one jurisdiction, with the ability and willingness to obtain additional unrestricted licenses, as needed, for states within the assigned region.
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• Board Certified in an approved ABMS Medical Specialty
• Prompt professional communication skills written and verbally
• 5 years of established clinical experience post residency
• Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Requirements

• Medical utilization management experience in MA Grievances and Appeals (preferred)
• Working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc. (preferred)
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, Anesthesiology, Physical Medicine and Rehabilitation, Emergency Medicine, Neurology, and General Surgery clinical specialists (preferred)

Benefits

• Competitive benefits that support whole-person well-being
• Medical, dental and vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• Short-term and long-term disability
• Life insurance
• Many other opportunities

Work Style

• Fully remote living in the contiguous USA. Occasional travel to Humana's offices for training or meetings may be required.

Work Hours

• Typical business hours are Monday-Friday, 8am - 5pm. Some flexibility might be possible, depending on business needs.
• Holidays and weekends as required by needs of the business.
• Very minimal travel might be required for training, meetings, and/or conferences.

Interview Format

• As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor.
• If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions.
• You should anticipate the assessment to take approximately 10-15 minutes.
• Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

• 40

Pay Range

• $246,100 - $344,200 per year
• This job is eligible for a bonus incentive plan based upon company and/or individual performance.

Application Deadline

• 11-29-2026

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.