Medical Director

The Medical Director reviews and determines whether healthcare services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and applicable contracts.

The Medical Director evaluates the medical necessity of healthcare services, ensuring decisions comply with regulatory and organisational standards. The role requires interpreting clinical guidelines, CMS policies, and Medicare requirements, and applying them consistently.

Role Responsibilities:

• Review clinical cases and determine medical necessity of services for Medicare and Medicaid members.
• Ensure compliance with review policies, procedures, and regulatory standards.
• Apply clinical guidelines, CMS policies, and Medicare/Medicare Advantage/Medicaid requirements.
• Identify opportunities for medical management operational improvements.
• Participate in call rotations, including weekend coverage and after-hours coverage.
• Contribute to an engaged, collaborative team culture that supports organisational excellence.
• Deliver exceptional consumer experiences.
• Participate in educational activities by attending required conferences and creating content to present for individual subject matter contribution.
• Support Home Solutions and other activities as assigned by the OneHome leadership.

Required Qualifications:

• MD or DO degree
• Current, active and ongoing board certification from the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialties (AOABPS)
• Current and unrestricted state license in at least one state and willing to obtain other medical licenses, as required, for various states in region of assignment
• No sanctions from Federal or State Governmental organisations
• 5 years of direct clinical patient care experience post residency or fellowship
• The ability to pass credentialing requirements
• Intermediate to advanced skills utilising Microsoft Office and Internet navigation
• Strong verbal and written communication skills, with the ability to analyse information and interpret data clearly and accurately
• Adaptable and willing to learn new technologies to enhance workflow efficiency

Preferred Qualifications:

• Experience in an inpatient and/or outpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
• Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, Surgery or hospital-based clinical specialists

Additional Information:

• Workstyle: Remote work at home
• Hours: Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, call rotations, including weekend coverage and after-hours coverage
• Training: 5 weeks of onboarding, no time off and training is in Eastern Standard Time (EST)

Scheduled Weekly Hours: 40

Pay Range: $223,800 - $313,100 per year

Description of Benefits: Humana, Inc. and its affiliated subsidiaries offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.