Medical Director – OP Medicare

Humana

Medical Director directing OP Medicare service authorizations and reviews within Humana's Medicare advantage programs. Collaborating with healthcare professionals to ensure appropriate resource utilization and regulatory compliance.

Posted 5/15/2026full-timeRemote • 🇺🇸 United StatesLead💰 $223,800 - $313,100 per yearWebsite

About the role

Key responsibilities & impact

Use clinical expertise, medical judgment, and experience to determine authorization for requested services, level of care, and site of service.
Perform medical necessity reviews in compliance with regulatory standards, CMS requirements, Humana policies, clinical guidelines, and applicable contractual obligations.
Apply knowledge of Medicare and Medicare Advantage requirements in daily utilization management and coverage determination activities.
Conduct computer-based review of moderately complex to complex clinical cases, primarily involving inpatient and post-acute care scenarios.
Review all submitted clinical documentation and records to support accurate, evidence-based determinations.
Interpret whether services rendered by other healthcare professionals align with national guidelines, clinical standards, CMS requirements, and internal policies.
Prioritize daily case review workload to ensure timely completion and adherence to compliance-driven turnaround times.
Communicate utilization review decisions and clinical determinations to internal associates and relevant stakeholders.
Speak regularly with external physicians to obtain additional clinical information, discuss determinations, and support peer-to-peer review processes.
Use conflict resolution skills when needed during physician discussions related to adverse determinations or clinical review outcomes.
Participate in care management activities when applicable to support quality, coordination, and appropriate resource utilization.
Provide oversight or input, as applicable, regarding coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment reviews.
Collaborate with internal team members, cross-functional departments, Humana colleagues, and regional health services leadership to support organizational and market goals.
Engage with contracted physicians, physician groups, facilities, and community organizations to support regional priorities and strengthen collaborative business relationships.
Contribute to initiatives related to value-based care, population health, disease management, and care management strategies.
Work effectively in a structured environment with strong expectations for consistency in clinical reasoning, written determinations, and documentation.
Perform daily responsibilities independently after mentored training, exercising sound judgment with minimal direction.
Meet departmental expectations for quality, consistency, productivity, and compliance timelines.

Requirements

What you’ll need

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/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 willing to obtain additional license, if required.
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
Excellent verbal and written communication skills.
Evidence of analytic and interpretation skills
The curiosity to learn, the flexibility to adapt and the courage to innovate.

Benefits

Comp & perks

medical, dental and vision benefits
401(k) retirement savings plan
time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
short-term and long-term disability
life insurance
many other opportunities

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical necessity reviewsutilization managementclinical documentationevidence-based determinationscoding practicescare managementvalue-based carepopulation healthdisease managementclinical reasoning

Soft Skills

communication skillsconflict resolutionanalytical skillsinterpretation skillscuriosityflexibilityinnovationindependent workteam collaborationtime management

Certifications

MD degreeDO degreeBoard Certificationunrestricted medical license