[Hiring] Medical Director National OP, Medicare @Humana

Role Description

The Medical Director relies on medical background and reviews preauthorization requests for services. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs with a context of regulatory compliance, and work is assisted by diverse resources which may include:

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

Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.

The Medical Director’s 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 or post-acute care environments. The Medical Director has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, 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

The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include:

• Understanding of Humana processes
• Focus on collaborative business relationships
• Value-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, preferably including some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
• Current and ongoing Board Certification in an approved ABMS Medical Specialty
• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
• Excellent verbal and written communication skills
• Evidence of analytic and interpretation skills
• The curiosity to learn, the flexibility to adapt and the courage to innovate

Requirements

• The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type
• May also engage in grievance and appeals reviews
• May participate on project teams or organizational committees

Preferred Qualifications

• Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid
• Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance
• Experience with national guidelines such as MCG® or InterQual
• Advanced degree such as an MBA, MHA, MPH
• Exposure to Public Health, Population Health, analytics, and use of business metrics
• Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health
• The curiosity to learn, the flexibility to adapt and the courage to innovate

Work Style

• Remote in the contiguous US, with 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 based on business needs

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$223,800 - $313,100 per year

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

Description of Benefits

• 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

Application Deadline

10-24-2026