Medical Director – PI, Claims

Humana

Medical Director responsible for clinical service determinations and compliance at Humana. Collaborating with teams to support effective patient care management and regulatory adherence.

Posted 7/29/2026full-timeRemote • 🇺🇸 United StatesLead💰 $223,800 - $313,100 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical interpretation and clinical decision-making aligned with national guidelines and CMS requirements, while effectively collaborating with cross-functional teams to achieve quality outcomes and operational goals.

Highest-signal resume keywords

MD Or DO Degree5+ Years Clinical Patient Care ExperienceBoard Certification In ABMS Medical SpecialtyAnalytic And Interpretation SkillsExcellent Verbal And Written Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Decision-MakingEvidence-Based Criteria ApplicationQuality ManagementUtilization ManagementCase ManagementDischarge PlanningHome Health ServicesPost-Acute Services

Soft Skills

ProfessionalismAccountabilityCollaboration

Certifications & Qualifications

Current And Unrestricted Medical License

Industry Keywords

CMS RequirementsClinical StandardsRegulatory GuidanceHealthcare ComplianceMedicare Population

About the role

Key responsibilities & impact

Provide medical interpretation and clinical determinations regarding whether services provided by healthcare professionals align with applicable national guidelines, CMS requirements, Humana policies, clinical standards, and relevant contract requirements
Review clinical information and apply evidence-based criteria to support consistent, compliant, and well-documented medical decisions
Collaborate with team members, cross-functional departments, Humana colleagues, and the Regional VP of Health Services to support departmental and market-wide objectives
Perform daily work with minimal direction after completion of mentored training, while maintaining alignment with departmental standards and expectations
Work effectively in a structured environment that requires consistency in clinical reasoning, decision-making, documentation, and authorship
Exercise independent judgment in meeting departmental expectations, operational goals, and compliance timelines
Support market-wide health objectives, including initiatives such as Bold Goal, and contribute to community relations activities as directed
Partner with internal stakeholders to promote quality outcomes, appropriate utilization, and adherence to clinical and regulatory requirements
Maintain current knowledge of applicable clinical standards, regulatory guidance, CMS requirements, and organizational policies relevant to medical decision-making
Communicate clinical determinations clearly and professionally to appropriate internal and external stakeholders
Contribute to process consistency, quality improvement, and operational effectiveness within the assigned area of responsibility
Demonstrate professionalism, accountability, and collaboration in support of Humana’s clinical, compliance, and business objectives

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 onboarding requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services such as inpatient rehabilitation.

Benefits

Comp & perks

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