Medical Director - National Utilization Management Team

Join our caring community and help prioritize health! The Medical Director utilizes their medical expertise and experience to evaluate requests for services and determine appropriate levels of care. This role is essential for ensuring regulatory compliance, supported by a variety of resources including national clinical guidelines and CMS policies. You will gain in-depth knowledge of Medicare and Medicare Advantage requirements and effectively apply this knowledge in your daily responsibilities. This position requires weekend work for one weekend each month, with compensation provided through days off during the work week. As a Medical Director, you will review submitted medical records, synthesize complex clinical scenarios, and provide expert decision-making regarding requested services. You will regularly communicate with external providers to gather necessary clinical information and engage in discussions about your determinations. You will foster collaborative relationships while ensuring that Humana's values are reflected in all your activities. Key Responsibilities: Conduct thorough, timely, and compliant medical necessity reviews for inpatient services. Accountable for meeting productivity, quality, and compliance metrics. Clearly communicate determinations both verbally and in writing. Show adaptability and a willingness to learn new workflows and utilization management practices. Participate in weekend work one weekend per month with compensated weekdays off. Make an impact with your skills! Required Qualifications: MD or DO degree. 5+ years of clinical patient care experience post-residency or fellowship, preferably in an inpatient setting or with Medicare populations. Current Board Certification in an approved ABMS Medical Specialty. A current, unrestricted medical license and willingness to obtain additional licenses as necessary. No current sanctions from federal or state organizations with ability to meet credentialing requirements. Excellent verbal and written communication skills. Demonstrated analytic and interpretation skills, with experience in team environments. Preferred Qualifications: Knowledge of the managed care industry, including Medicare Advantage and Managed Medicaid. Utilization management experience in a medical management context. Familiarity with national guidelines such as MCG or InterQual. Experience in hospital-based practice, particularly in Internal Medicine, Family Practice, Geriatrics, or Emergency Medicine. A desire to learn and adapt to enhance efficiency and productivity. Proven success in a dynamic, team-oriented environment. Commitment to innovation, including the use of technology to improve workflows. Engagement in educational activities and professional development. Passion for improving consistency in outcomes and enhancing consumer experiences. Additional Information: The Medical Director reports to a Lead Medical Director. Weekend participation on a rotational basis is required to ensure timely case decisions. This role may also include participation in project teams or organizational committees. This is a remote position; occasional travel to Humana offices for training or meetings may be required. Scheduled Weekly Hours: 40 Pay Range: $223,800 - $313,100 per year, with eligibility for a bonus incentive plan based on performance. Description of Benefits: Humana offers competitive benefits supporting personal wellness and smart healthcare decisions, including medical, dental, vision, retirement savings, paid time off, and more. Application Deadline: 04-30-2026 About Us: Humana Inc. is dedicated to putting health first for our teammates and the communities we serve. Equal Opportunity Employer: Humana embraces diversity and does not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, disability, or veteran status. We also comply with all federal civil rights laws.

Created: 2026-03-05