Medical Director – Grievances & Appeals

Humana

Corporate Medical Director relying on medical background for healthcare appeals and grievances. Ensuring service appropriateness, compliance and continuous improvement in consumer experience.

Posted 5/20/2026full-timeRemote • California, Illinois, Montana, South Dakota • 🇺🇸 United StatesLead💰 $246,100 - $344,200 per yearWebsite

About the role

Key responsibilities & impact

Provide clinical interpretation and determinations on the medical appropriateness of services delivered by healthcare professionals, including the application of evidence-based guidelines.
Make independent, timely, and defensible medical decisions on complex appeal cases, exercising professional judgment with minimal supervision.
Collaborate with cross-functional teams—including legal, compliance, and clinical operations—to address and resolve grievances and appeals.
Participate in quality improvement initiatives, identifying trends in grievances and appeals and recommending process improvements.
Serve as a clinical resource for grievance and appeals staff, providing guidance and education as needed.
Maintain current knowledge of Medicare regulations, managed care requirements, and industry best practices relevant to appeals and grievances.
Support Humana’s commitment to continuous improvement in consumer experience, ensuring fair, consistent, and customer-focused outcomes.
Participate in internal and external audits as required and respond to regulatory inquiries as needed.
Adhere to all confidentiality and HIPAA requirements in handling protected health information (PHI).

Requirements

What you’ll need

MD or DO degree completed at an accredited university in the USA
A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment
Board Certified in an approved ABMS/ABOA Medical Specialty
5 years of established clinical experience
Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
Possess analysis and interpretation skills with prior experience leading teams focusing on quality management.
Experience with discharge planning and/or home health or rehab

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical interpretationevidence-based guidelinesmedical decision makingquality improvementgrievance resolutionappeals managementdischarge planninghome healthrehabilitation

Soft Skills

professional judgmentcollaborationguidanceeducationanalysisinterpretationleadershipcommunicationproblem-solving

Certifications

MD degreeDO degreeunrestricted medical licenseBoard Certified in ABMS/ABOA Medical Specialty