Lead MD Grievances & Appeals

Lead Medical Director

Become a part of our caring community

The Lead Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing appeals for Medicare Line of Business. The Lead Medical Director requires a solid understanding of how organization capabilities interrelate across department(s) and the fundamentals of using data analytics to drive results and trends. Candidates may live anywhere in the US, but must be willing to work East Coast hours. This role will work closely with our Appeal Strategy, Nurse Leaders and adjacent stakeholders and business partners.

The Lead Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s) and could lead multiple highly specialized professional associates. The Lead Medical Director will be responsible for driving and managing the team's culture and engagement.

Schedule is Monday-Friday with alternating weekend supervision AND an occasional weekend shift with days off during the week

Use your skills to make an impact

Required Qualifications

• 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 licenses, as required, for various states in region of assignment
• 5+ years of direct clinical patient care experience post-residency or fellowship
• No current sanction from Federal or State Governmental organizations and the ability to satisfy onboarding requirements
• Excellent verbal and written communication skills with analytic and interpretative skills from prior experience focusing on quality, utilization, and/or case management
• Knowledge and experience with national guidelines such as NCD/LCD, MCG or InterQual

Preferred Qualifications

• Demonstrated experience in operations and performance management
• Demonstrated experience with appeals review cases with completion of training
• Experience in an inpatient and/or care of a Medicare type population (disabled or >65 years of age)
• Internal Medicine, Family Practice, Geriatrics, General Surgery, Neurology, Anesthesia background
• Two or more years of management experience leading teams in dynamic environments
• Commitment to a culture of innovation, diversity, equity, and inclusion
• Passionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team culture

Reporting Structure

In conjunction with the other G&A Lead Medical Directors, this position oversees the operations of the team, ensures timely completion of cases by the team to meet Medicare requirements, and oversees the work of Medical Directors who conduct appeals clinical case reviews for Medicare and Dual Eligible populations. The Lead Medical Director may also lead specific functional areas in addition to leading a team of Medical Directors. The role reports to the Director of Physician Leadership.

Other Duties:

• Maintain medical director schedule (PTO, weekend coverage, etc.)
• Develop collaborative relationships with key partners within the Medicare Line of Business, including with internal team associates and leadership
• This position will require 50% case review.
• Manage regular meetings with various company participants
• Foster development of medical directors through non-case review activities
• Support team pursuit of CMS Star success in Timeliness and Fairness measures
• Other activities as assigned by the Director of Physician Leadership

Work Style: Fully Remote; Very minimal travel might be required for training, meetings, and/or conferences

Work Hours: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week-- some flexibility might be possible, depending on business needs.

Interview Format

As 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 will subsequently be informed if you will be moving forward to next round of interviews.

SSN Task via Workday

Should 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.

Work 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 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 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. $270,800 - $378,800 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 Humana, 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: 09-10-2026

About us

About 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 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. 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