Medical Director – OP Medicare

Humana

. Determine authorization for requested services, level of care, and site of service .

Posted 9/22/2026full-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, clinical review, and compliance with regulatory standards, including Medicare and Medicaid guidelines. Strong analytical skills and effective communication abilities are essential for collaborating with healthcare professionals and managing complex clinical cases.

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 ReviewMedical Necessity ReviewCompliance EvaluationClinical Documentation OversightNational Clinical Guidelines ApplicationGrievance And Appeals ReviewCare CoordinationData AnalysisCase Management

Soft Skills

Excellent Communication SkillsAnalytical SkillsJudgment EvaluationCollaboration SkillsConflict Resolution

Certifications & Qualifications

Current And Unrestricted Medical LicenseBoard Certification In ABMS Medical Specialty

Industry Keywords

Medicare AdvantageManaged MedicaidPopulation HealthValue-Based CareClinical CriteriaCMS RequirementsHealth Services LeadershipSocial Determinants Of HealthCare Management InitiativesPublic Health

About the role

Key responsibilities & impact

Determine authorization for requested services, level of care, and site of service
Perform medical necessity and coverage reviews in compliance with regulatory standards, CMS requirements, Medicare and Medicare Advantage guidelines, clinical criteria, Humana policies, and contractual obligations
Conduct computer-based reviews of moderately complex to complex clinical cases, primarily involving inpatient and post-acute care
Evaluate services against national guidelines, clinical standards, CMS requirements, and internal policies
Prioritize and manage daily case review workload to meet compliance-driven turnaround times
Communicate utilization review decisions and clinical determinations to internal associates and stakeholders
Collaborate with external physicians to obtain clinical information, discuss determinations, support peer-to-peer reviews, and resolve conflicts during adverse determination discussions
Participate in care management activities supporting quality outcomes, care coordination, and resource utilization
Provide oversight or input on coding, clinical documentation, grievance and appeals processes, and outpatient services and equipment reviews
Collaborate with internal teams, cross-functional partners, Humana colleagues, and regional health services leadership
Engage with contracted physicians, physician groups, facilities, and community organizations
Contribute to value-based care, population health, disease management, and care management initiatives
Work independently after mentored training while meeting quality, consistency, productivity, documentation, and compliance expectations
Conduct utilization management reviews for members within an assigned market, member population, or clinical condition
Participate in grievance and appeals reviews, project teams, and organizational committees as applicable

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 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
Demonstrated analytical and interpretive skills
Ability to evaluate information and make informed judgments
Knowledge of the managed care industry, including Medicare Advantage and Managed Medicaid
Utilization management experience in a medical management review organization
Experience applying national clinical guidelines such as MCG® or InterQual®
Advanced degree such as an MBA, MHA, or MPH preferred
Exposure to Public Health, Population Health, analytics, and business metrics
Experience collaborating with Case Managers or Care Managers on complex case management
Familiarity with social determinants of health

Benefits

Comp & perks

Bonus incentive plan based on company and/or individual performance
Medical benefits
Dental benefits
Vision benefits
401(k) retirement savings plan
Paid time off
Company holidays
Personal holidays
Paid parental leave
Paid caregiver leave
Short-term disability
Long-term disability
Life insurance
Remote work
Occasional travel to Humana offices for training or meetings
Work-from-home internet and dedicated workspace requirements to support effective remote work