Medical Director - Nat'l UM Team wknd​/mo

Overview

The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, level of care, and/or site of service should be authorized. All work occurs within a regulatory compliance context 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 learn Medicare and Medicare Advantage requirements and understand how to operationalize this knowledge daily.

Weekend work is required one weekend per month with compensated days off during the work week.

• Review all submitted medical records, synthesize complex hospital‑based clinical scenarios, and provide expert decisioning on requested services.
• Engage in regular discussions with external providers by phone to gather additional clinical information and discuss determinations.
• Understand Humana processes and maintain collaborative professional relationships.
• 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.
• Exercise independence in meeting departmental expectations and compliance timelines.
• Weekend work is required one weekend per month with compensated days off during the work week.

• MD or DO degree.
• 5+ years of direct clinical patient‑care experience post‑residency or fellowship, preferably in an inpatient environment and/or in care of a Medicare‑type population.
• Current and ongoing Board Certification in an approved ABMS Medical Specialty.
• Active and unrestricted license in at least one jurisdiction; willing to obtain additional license if required.
• No current sanctions from Federal or State governmental organizations and able 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, or Commercial products, and other medical‑management organizations.
• Utilization‑management experience in a medical‑management review organization.
• Experience with national guidelines such as MCG® or Inter Qual.
• Hospital‑based clinical practice experience, including specialties of Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and hospital‑based clinical specialists.
• Curiosity to learn and 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 activities by attending required conferences and by creating content to lead/teach/present for individual subject‑matter contribution.
• Passion for contributing to an organization’s focus on consistency in outcomes, consumer experiences, and a highly engaged team culture.

• The medical director reports to a Lead Medical Director.
• Participation in weekend work on a rotational basis to ensure cases are decisioned in a timely manner.
• May participate on project teams or organizational committees.
• 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: $223,800 – $313,100 per year (full‑time, 40 hours per week). This range may vary by geography and individual qualifications. The position is eligible for a bonus incentive plan based upon company and/or individual performance.

Humana offers competitive benefits that support whole‑person well‑being. Benefits include medical, dental, and vision coverage; 401(k) retirement…