Corporate Medical Director

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The Corporate 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. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, Uses independent judgment requiring analysis of variable factors and determining the best course of action.

The Corporate Medical Director provides medical interpretation, clinical review, and strategic medical leadership to support Humana’s One Home initiatives. This role reviews health claims and clinical requests to determine the appropriateness and medical necessity of services provided by healthcare professionals, including Home Care Solutions, Skilled Nursing Facility, Durable Medical Equipment, rehabilitation, discharge planning, and related home care solutions.

• Review clinical cases, health claims, and service requests to determine the medical necessity and appropriateness of care provided by healthcare professionals.
• Evaluate requests involving Home Care Solutions, Skilled Nursing Facility services, Durable Medical Equipment, rehabilitation, discharge planning, and other home-based care solutions.
• Apply CMS Medicare guidance, Medicare Advantage requirements, Medicaid requirements, national clinical guidelines, Humana policies, clinical standards, review procedures, performance standards, and applicable contracts.
• Provide medical interpretation and clinical rationale for determinations involving Medicare, Medicaid, Commercial, and dual-eligible populations, as applicable.
• Ensure decisions are timely, fair, consistent, compliant, and evidence based.
• Analyze complex clinical scenarios and variable factors to determine the most appropriate course of action.

• Advise executives and business leaders on functional strategies related to One Home and segment-specific clinical priorities.
• Serve as a clinical subject matter expert on matters of significance involving home-based care, post-acute services, utilization management, quality management, discharge planning, and care coordination.
• Exercise independent judgment and decision-making on complex issues related to clinical review operations and medical management strategy.
• Support the development and refinement of policies, procedures, workflows, and performance standards that improve review quality and operational consistency.
• Contribute to scalable strategies that support One Home and the evolving needs of Medicare, Medicaid, Commercial, and dual-eligible populations.

• Identify opportunities to improve medical management operations, workflow efficiency, case turnaround times, review consistency, and service delivery.
• Analyze clinical information, utilization patterns, operational data, and performance trends to identify gaps, risks, and opportunities.
• Support initiatives focused on quality management, utilization management, discharge planning, home care solutions, rehabilitation, and post-acute care performance.
• Partner with operational teams to simplify processes, reduce unnecessary complexity, and improve consistency across review activities.
• Promote the use of technology, standardized workflows, and data-driven decision-making to enhance operational effectiveness.

• Ensure clinical review activities comply with applicable federal and state laws, CMS guidance, Medicare Advantage requirements, Medicaid requirements, Humana policies, and contractual obligations.
• Support adherence to review policies, procedures, performance standards, and regulatory timelines.
• Promote compliance-focused decision-making across clinical review and medical management activities.
• Help ensure determinations are supported by appropriate documentation, clinical rationale, and evidence-based standards.
• Identify…