Medical Director - OP Medicare

Become a part of our caring communityThe Medical Director, National Outpatient Medicare leverages clinical expertise and medical judgment to review preauthorization requests for services. This role is responsible for evaluating moderately complex to complex cases, where analysis of clinical information and situational factors requires in-depth assessment and sound decision-making.As a Medical Director at Humana, you will use your clinical expertise and judgment to make meaningful coverage and care determinations that support quality, consistency, and compliance across the healthcare continuum. In this role, you will review requests for services, level of care, and site of service, using nationally recognized clinical guidelines, CMS policies, medical references, and internal clinical resources to guide decision-making.This position offers the opportunity to work on complex outpatient cases, review clinical documentation, and collaborate with both internal partners and external physicians to gather additional information and discuss determinations. You may also contribute to care management activities and, depending on the role, provide input on areas such as clinical documentation, coding, grievances and appeals, and outpatient services or equipment reviews.Beyond case review, this role provides the opportunity to build strong relationships with physicians, provider groups, facilities, and community partners in support of regional priorities. It is a strong fit for physicians who are interested in contributing to value-based care, population health, and care management strategies while working in a structured environment that values sound clinical judgment, collaboration, and operational excellence.Humana is seeking a Medical Director to apply clinical expertise and judgment in reviewing complex outpatient cases, making coverage determinations, and supporting high-quality, compliant utilization management practices. This role offers the opportunity to collaborate with physicians and cross-functional partners, contribute to care management and appeals-related activities, and help advance Humana's focus on value-based care, population health, and improved health outcomesUse your skills to make an impactResponsibilitiesUse clinical expertise, medical judgment, and experience to determine authorization for requested services, level of care, and site of service.Perform medical necessity and coverage reviews in compliance with regulatory standards, CMS requirements, Medicare and Medicare Advantage guidelines, clinical criteria, Humana policies, and contractual obligations.Conduct computer-based review of moderately complex to complex clinical cases, primarily involving outpatient care, using submitted clinical documentation and records to support accurate, evidence-based determinations.Evaluate whether services rendered by healthcare professionals align with national guidelines, clinical standards, CMS requirements, and internal policies.Prioritize and manage daily case review workload to ensure timely completion and adherence to compliance-driven turnaround times.Communicate utilization review decisions and clinical determinations to internal associates and other relevant stakeholders.Collaborate with external physicians to obtain additional clinical information, discuss determinations, support peer-to-peer reviews, and apply conflict resolution skills when needed during adverse determination discussions.Participate in care management activities, when applicable, to support quality outcomes, care coordination and appropriate resource utilization.Provide oversight or input, as applicable, regarding coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment reviews.Collaborate with internal team members, cross-functional partners, Humana colleagues, and regional health services leadership to support organizational, market, and regional goals.Engage with contracted physicians, physician groups, facilities, and community organizations, and contribute to value-based care, population health, disease management and care management initiatives.Work independently in a structured environment after mentored training, exercising sound judgement with minimal direction and meeting departmental expectations for quality, consistency, productivity, documentation and compliance timelines.Required QualificationsMD or DO degree5 years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an outpatient 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 SpecialtyA 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, with a professional and responsive approach.Demonstrated analytical and interpretive skills, with the ability to evaluate information and make informed judgments.A strong desire to learn, flexibility to adapt to change, and the courage to innovate and improve processes.Preferred QualificationsKnowledge of the managed care industry, including Medicare Advantage and Managed Medicaid.Utilization management experience in a medical management review organization, including Medicare Advantage, Managed Medicaid or Commercial health insurance.Experience applying national clinical guidelines such as MCG or InterQualAdvanced degree preferred, such as an MBA, MHA, or MPHExposure to Public HealthPopulation Health, analytics and business metrics.Experience collaborating with Case Managers or Care Managers on complex case management, including familiarity with social determinants of healthIntellectual curiosity, adaptability and the courage to innovate.Additional InformationTypically reports to a Regional Vice President of Health Services, Lead Medical Director, or Corporate Medical Director, depending on the size of the region or line of business. The Medical Director is responsible for conducting utilization management reviews for care provided to members within an assigned market, member population, or clinical condition. This role may also include participation in grievance and appeals reviews, as well as involvement in project teams and organizational committees.Work Style: Remote - Occasional travel to Humana's offices for training or meetings may be required.Work Hours Typical business hours are Monday-Friday, 8 hours/day, 5 days/week- some flexibility might be possible, depending on business needs.Interview FormatAs part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers with an enhanced method for decision-making through on-demand candidate assessments.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 subsequently will be informed if you will be moving forward to next round of interviews.SSN Task via WorkdayShould you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.physiciancareersWork at Home Requirements: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours40Pay RangeThe 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 yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, Humana) 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.Application Deadline: 10-05-2026About usAbout Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.Equal Opportunity EmployerIt 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. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our Humana