[Hiring] Medical Director - Claims @Humana

Role Description

The Medical Director uses their medical background, experience, and judgement to make determinations regarding:

• Authorization of requested services
• Request level of care
• Requested site of service at the Initial or Appeals/Disputes level

All work occurs within a context of regulatory compliance, utilizing diverse resources such as:

• National clinical guidelines
• CMS policies and determinations
• Clinical reference materials
• Internal teaching conferences
• Other reference sources

You will learn Medicare, Medicaid, and Medicare Advantage requirements and understand how to operationalize this knowledge in daily work.

Your work includes:

• Computer-based review of moderately complex to complex clinical scenarios
• Review of all submitted clinical records
• Prioritization of daily work
• Communication of decisions to internal associates
• Possible participation in care management

The clinical scenarios predominantly arise from:

• Inpatient
• Outpatient
• Post-acute care environments

You will engage with external physicians to:

• Gather additional clinical information
• Discuss determinations, which may require conflict resolution skills

Some roles include an overview of:

• Coding practices and clinical documentation
• Grievance and appeals processes
• Outpatient services and equipment

You may also support regional market priorities through discussions with:

• Contracted external physicians
• Physician groups
• Facilities
• Community groups

These priorities may include:

• Understanding of Humana processes
• Focus on collaborative business relationships
• Values-based care
• Population health
• Disease or care management

Qualifications

• MD or DO degree
• 5+ years of direct clinical patient care experience post residency or fellowship, including inpatient environment and care of a Medicare type population
• Current and ongoing Board Certification in an approved ABMS or AOA Medical Specialty
• Current and unrestricted license in at least one jurisdiction
• No current sanction from Federal or State Governmental organizations
• Evidence of analytic and interpretation skills
• Knowledge of the managed care industry
• Utilization management experience in a medical management review organization
• Experience with national guidelines such as MCG® or InterQual
• Clinical specialists in Internal Medicine, Family Practice, Geriatrics, Hospitalist, and Emergency Medicine

Requirements

• Advanced degrees such as an MBA, MHA, MPH (preferred)
• Exposure to Public Health, Population Health, analytics, and use of business metrics (preferred)
• Experience working with Case managers or Care managers on complex case management (preferred)

Benefits

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

Work at Home Guidance

• Minimum download speed of 25 Mbps and upload speed of 10 Mbps recommended
• Wireless, wired cable or DSL connection suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Bi-weekly payment for internet expense for associates in California, Illinois, Montana, or South Dakota
• Humana will provide telephone equipment appropriate for business requirements
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
• Occasional travel to Humana's offices for training or meetings may be required

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment:

$223,800 - $313,100 per year

This job is eligible for a bonus incentive plan based on company and/or individual performance.

Application Deadline

10-25-2026

Equal Opportunity Employer

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