Medical Director – Medicaid

Humana

. Review health claims and clinical records .

Posted 11/12/2026full-timeRemote • United StatesLead💰 $223,800 - $313,100 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Utilization Management, applying national clinical guidelines and policies while conducting clinical reviews and making medical determinations. Strong communication and analytic skills are essential for collaborating with internal teams and external physicians.

Highest-signal resume keywords

MD Or DO Degree5+ Years Clinical Patient Care ExperienceBoard Certification In ABMS Medical SpecialtyUtilization Management ExperienceKnowledge Of Managed Care Industry

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Utilization ManagementClinical ReviewAnalytic SkillsCase ManagementDischarge PlanningQuality ManagementClinical Guidelines ApplicationMedical DeterminationsPopulation HealthDisease Management

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationConflict ResolutionTeam CollaborationInterpersonal Skills

Tools & Technologies

MCG®InterQual

Certifications & Qualifications

Board Certification In ABMS Medical SpecialtyCurrent Louisiana LicenseCurrent Oklahoma License

Industry Keywords

Medicare AdvantageManaged MedicaidCommercial ProductsPublic HealthSocial Determinants Of Health

About the role

Key responsibilities & impact

Review health claims and clinical records
Determine whether requested services, levels of care, and sites of service should be authorized
Apply national clinical guidelines, CMS policies, clinical standards, Humana policies, and contracts
Prioritize daily computer-based clinical review work
Communicate determinations to internal associates
Discuss cases with external physicians by phone and gather additional clinical information
Resolve conflicts related to medical determinations when necessary
Participate in care management, grievance and appeals reviews, project teams, and organizational committees
Conduct Utilization Management for members in an assigned market, population, or condition type
Support regional market priorities, value-based care, population health, disease management, and care management initiatives
Collaborate with team members, departments, Humana colleagues, and the Regional VP Health Services
Complete mentored training and then perform daily work with minimal direction
Support market-wide objectives and community relations as directed
Typically report to a Regional Vice President of Health Services, Lead, or Corporate Medical Director

Requirements

What you’ll need

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship
Current and ongoing Board Certification in an approved ABMS Medical Specialty
Current Louisiana and Oklahoma licenses, and/or ability to obtain additional licenses without conditions
No current sanction from Federal or State Governmental organizations
Able to pass credentialing requirements
Position open to all US Territory, with requirement to work 8am-5pm Central Standard Time
Excellent verbal and written communication skills
Analytic and interpretation skills
Prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services
Ability to conduct Utilization Management
Preferred: knowledge of managed care industry, Medicare Advantage, Managed Medicaid and/or Commercial products
Preferred: utilization management experience in a medical management review organization
Preferred: experience with MCG® or InterQual
Preferred: Family Practice, Pediatrics, Physical Medicine Rehabilitation, or Emergency Medicine specialization
Preferred: advanced degree such as MBA, MHA, or MPH
Preferred: exposure to Public Health, Population Health, analytics, and business metrics
Preferred: experience working with Case managers or Care managers on complex case management and familiarity with social determinants of health

Benefits

Comp & perks

Bonus incentive plan based on company and/or individual performance
Medical, dental and vision benefits
401(k) retirement savings plan
Paid time off
Company and personal holidays
Paid parental and caregiver leave
Short-term and long-term disability
Life insurance
Dedicated home workspace and internet requirements for remote work
Occasional travel to Humana offices for training or meetings