Medical Director - Nat'l UM Team Alt Weekends

Job Overview

Become a part of our caring community and help us put health first.

The Medical Director uses their medical background, experience, and judgment to determine whether requested services, level of care, and/or site of service should be authorized. All work occurs within a context of regulatory compliance and is assisted by diverse resources, including national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.

Willingness to work every other weekend with compensated days off during the work week.

The Medical Director’s work includes reviewing all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services. They will have regular discussions with external providers by phone to gather additional clinical information and discuss determinations. Medical directors are expected to understand Humana processes with a focus on collaborative professional relationships. The ideal candidate has a high degree of integrity, professionalism, resourcefulness, and enjoys working in a team-based environment.

Medical Directors support Humana’s value throughout all activities.

The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. After completion of structured and mentored training, daily work is performed with minimal direction, but with ready support from other team members. The ideal candidate enjoys working in a structured environment with expectations for consistency in thinking and authorship, exercises independence in meeting departmental expectations, and meets compliance timelines.

• Conduct comprehensive, timely, and compliant medical necessity reviews for inpatient services
• Maintain accountability for productivity, quality, and compliance metrics
• Communicate determinations clearly both verbally and in writing
• Demonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practices

• MD or DO degree
• 5+ years of direct clinical patient care experience post‑residency or fellowship, preferably including 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 willingness to obtain additional license, if required
• No current sanction from Federal or State Governmental organizations, and ability to pass credentialing requirements
• Excellent verbal and written communication skills
• Evidence of analytic and interpretation skills, with prior experience working in a team environment

• Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid, and/or Commercial products, or other Medical management organizations, hospitals/Integrated Delivery Systems, health insurance, or other healthcare providers
• 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 Inter Qual
• Experience in hospital‑based clinical practice, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and hospital‑based clinical specialists
• The curiosity to learn and the flexibility to adapt to changes in order to enhance efficiency, productivity, and organizational goals
• Ability to thrive in a dynamic fast‑paced, team‑oriented environment
• Commitment to a culture of innovation, including being facile with using technology to improve workflows
• Participation in educational…