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The Medical Director uses their medical background, experience, and judgement to determine whether to authorize requested services, requested level of care, and requested site of service. All work occurs within a context of regulatory compliance, and diverse resources assist work, 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 specifically for DSNP.
The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, and communication of decisions to internal associates. The clinical scenarios predominantly arise from post-acute care environments. The work includes discussions with external physicians by phone to gather additional clinical information or discuss determinations, and in some instances, these may require conflict resolution skills. Responsibilities
Provide medical interpretation and determinations on acute inpatient rehabilitation authorization requests, ensuring alignment with national clinical guidelines, CMS requirements, Humana policies, and clinical standards.
Collaborate with team members, other departments, Humana colleagues, and clinical leadership to support the review process and facilitate quality outcomes.
Participate in and complete structured and mentored training programs; utilize ongoing team support during daily work activities.
Consistently apply critical thinking and maintain high standards in documentation and decision-making within a structured work environment.
Exercise independence in fulfilling enterprise expectations and meeting compliance timelines.
This is a full-time, remote position with a standard schedule of forty hours per week; the role may be performed from any location within the United States.
Required Qualifications
MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and related to acute inpatient rehabilitation.
Board Certified in an approved ABMS or AOA Medical Specialty with continued certification throughout employment.
A current and unrestricted license in at least one jurisdiction and willing to obtain additional license(s).
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, and acute inpatient rehabilitation.
Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid, or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers.
Utilization management experience in a medical management review organization, such as Medicare Advantage and managed Medicaid.
Physical Medicine and Rehabilitation, Internal Medicine, Family Practice, Geriatrics, or Hospitalist background
Preferred
Advanced degrees such as an MBA, MHA, MPH
Exposure to Public Health, Population Health, analytics, and use of business metrics.
Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health.
Use your skills to make an impact
Additional Information
Typically reports to a Regional/Associate Vice President, Lead, or Corporate Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May also contribute to grievance and appeals reviews. Some medical directors may join a centralized team for several months after training, until positions become available for specific markets. May participate on project teams or organizational committees.
Work Style: This is a fully remote position, applicants must live in the contiguous United States. Occasional travel to Humana 's offices for training or meetings may be required.
Work Hours: Typical business hours are Monday-Friday 40 hours per week (start as early as 6am, no later than 9am; 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 the next round of interviews.
SSN Task via Workday: Should you receive a formal employment offer, you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.
Reporting Structure: The Compliance Professional 2 reports to the Manager, Compliance
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.$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 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: 10-29-2026
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.
