Medical Director - Inpatient Claims Management

Join our compassionate community and prioritize health! The Medical Director plays a vital role by leveraging their medical expertise to determine the authorization of requested services, care levels, and service sites. This work is conducted within a framework of regulatory compliance, utilizing a variety of resources including national clinical guidelines, CMS and state regulations, and clinical reference materials. As a Medical Director, you will gain knowledge of Medicare, Medicare Advantage, and Medicaid intricacies to apply in your daily operations. Your responsibilities will involve computer-based evaluations of moderately complex to complex clinical situations, thorough review of clinical records, effective prioritization of daily tasks, and direct communication of decisions to your team. You may also engage in care management discussions with external physicians to obtain additional clinical information or resolve conflicts as needed. Some positions may include oversight of coding practices, clinical documentation, or the appeals process within your expertise. The Medical Director will interact with external physicians, physician groups, facilities, or community organizations to advance regional market objectives, emphasizing an understanding of Humana processes, collaborative relationships, value-based care, population health, or disease management. Throughout all activities, you will be an ambassador of Humana’s values. Make a significant impact using your skills! Key Responsibilities: Provide medical interpretation and make decisions on whether services align with national guidelines, CMS and state Medicaid regulations, Humana policies, and clinical standards. Collaborate effectively with team members and other departments to support collective goals and community relations. Work independently with minimal supervision following completion of mentored training, and maintain consistency and compliance in all tasks. Required Qualifications: MD or DO degree. 5+ years of hands-on clinical patient care experience post-residency or fellowship, ideally including inpatient environment experience or care for Medicare demographic. Current and ongoing board certification in an approved ABMS medical specialty. An active and unrestricted license in at least one jurisdiction, with a willingness to obtain additional licenses if necessary. No existing sanctions from federal or state government entities, and the ability to meet credentialing requirements. Exceptional verbal and written communication skills. Demonstrated analytic skills and experience participating in teams focused on quality management, case management, or post-acute services. Preferred Qualifications: Knowledge of the managed care sector including Medicare Advantage, Managed Medicaid, and Commercial products. Experience in utilization management within a medical review organization. Familiarity with national guidelines like MCG® or InterQual. Clinical specialization in Internal Medicine, Family Practice, Geriatrics, or other related fields. Possession of an advanced degree such as an MBA, MHA, or MPH. Exposure to Public Health and Population Health analytics. Experience collaborating with Case and Care Managers on complex case management. A curious mindset, flexibility to adapt, and willingness to innovate. Additional Information: This position typically reports to a Lead Medical Director. The Medical Director is responsible for conducting Utilization Management or clinical validation related to members' care in specific lines of business or population health issues. Additional opportunities for engagement in dispute and appeals reviews and project team participation are available. Travel may be required occasionally for training or meetings at Humana’s offices, although this is primarily a remote role. Scheduled Weekly Hours: 40 Compensation Range: $223,800 - $313,100 annually, with eligibility for a bonus incentive plan based on performance. About Humana: Humana Inc. prioritizes health for our teammates, customers, and operations. Through our insurance services and healthcare offerings, we aim to make healthcare access easier for millions, enhancing quality of life for those we serve. Equal Opportunity Employer: Humana is committed to workplace equality and does not discriminate against employees or applicants based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or veteran status. We focus on valid job requirements for all employment actions. Humana also complies with all federal civil rights laws and offers free language interpreter services as needed.

Created: 2026-03-11