Medical Director – National OP Medicare

Humana

. Review preauthorization requests for services .

Posted 11/2/2026full-timeRemote • United StatesLead💰 $223,800 - $313,100 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical decision-making and utilization management, with a strong foundation in national clinical guidelines and compliance standards. Proficient in communication and collaboration with healthcare professionals to ensure quality patient care and adherence to regulatory requirements.

Highest-signal resume keywords

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Record ReviewUtilization ManagementAnalytic SkillsClinical Documentation ReviewCoding Practices ReviewGrievance And Appeals ProcessesComplex Case ManagementMedical InterpretationKnowledge Of National GuidelinesPopulation Health Analytics

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationConflict ResolutionCollaborationTeamwork

Tools & Technologies

CMS PoliciesMCG® GuidelinesInterQual GuidelinesBusiness Metrics

Certifications & Qualifications

Current And Unrestricted Medical LicenseBoard Certification

Industry Keywords

Managed CareMedicare AdvantageManaged MedicaidPublic HealthSocial Determinants Of Health

About the role

Key responsibilities & impact

Review preauthorization requests for services
Make determinations on requested services, levels of care, and sites of service
Review clinical records and complex clinical scenarios using national clinical guidelines, CMS policies, clinical references, and Humana policies
Prioritize daily computer-based review work
Communicate decisions to internal associates
Participate in care management when applicable
Discuss cases and determinations with external physicians by phone
Gather additional clinical information and resolve conflicts when necessary
Review coding practices, clinical documentation, grievance and appeals processes, outpatient services, and equipment within scope
Support regional market priorities through communication with external physicians, physician groups, facilities, or community groups
Provide medical interpretation and determinations for healthcare services
Collaborate with team members, departments, Humana colleagues, and the Regional VP Health Services
Complete mentored training and perform daily work with minimal direction
Meet departmental expectations, compliance timelines, and standards for consistency
Conduct utilization management for members in an assigned market, population, or condition type
Participate in grievance and appeals reviews, project teams, or organizational committees

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/AOA Medical Specialty
Current and unrestricted license in at least one jurisdiction
Willingness to obtain additional license, if required
No current sanction from Federal or State Governmental organizations
Ability to pass credentialing requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills
Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid (preferred)
Utilization management experience in a medical management review organization (preferred)
Experience with national guidelines such as MCG® or InterQual (preferred)
Advanced degree such as an MBA, MHA, or MPH (preferred)
Exposure to Public Health, Population Health, analytics, and use of business metrics (preferred)
Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health (preferred)
Minimum home internet speed of 25 Mbps download and 10 Mbps upload
Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

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
Work-from-home arrangement
Occasional travel to Humana offices for training or meetings
Dedicated workspace and internet requirements to support remote work