Medical Director – Physical Health

Humana

. Develop and support Medicaid care strategy and/or operations .

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

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Medicaid care strategy and operations, ensuring regulatory compliance while applying clinical guidelines and policies. Proficient in utilization management, case management, and fostering collaborative relationships with healthcare providers and stakeholders.

Highest-signal resume keywords

Doctor Of MedicineBoard-Certified In Medical SpecialtyUtilization Management ReviewExperience With Medicaid EnrolleesAccreditation Process (NCQA)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ServicesCase ManagementUtilization ManagementClinical ReviewConflict ResolutionPeer-To-Peer DiscussionsOperationalizing Medicaid RequirementsComputer-Based ReviewPopulation Health InitiativesValue-Based Care

Soft Skills

CommunicationCollaborationPrioritizationProblem-SolvingFlexibility

Tools & Technologies

CGXMHKElectronic Health RecordsTelehealth Platforms

Certifications & Qualifications

Current Medical LicenseBoard CertificationLicensure Through IMLC

Industry Keywords

MedicaidRegulatory ComplianceClinical GuidelinesHealth Plan SettingPeer Review ProcessHealthcare ProvidersStakeholder EngagementDisease ManagementCare ManagementFederal And State Regulations

About the role

Key responsibilities & impact

Develop and support Medicaid care strategy and/or operations
Determine whether requested services, levels of care, or sites of service should be authorized
Apply national clinical guidelines, state policies, CMS policies, clinical references, and internal resources while ensuring regulatory compliance
Learn Medicaid requirements and operationalize them in daily work within the assigned cluster
Conduct computer-based review of complex clinical scenarios and submitted clinical records
Prioritize daily work and communicate decisions to internal associates
Participate in care management as needed for outpatient and inpatient clinical scenarios
Conduct phone discussions with external physicians to gather clinical information or discuss determinations through peer-to-peer processes
Resolve conflicts during physician discussions when necessary
Support regional market priorities through engagement with physicians, physician groups, facilities, and community groups
Support collaborative business relationships, value-based care, population health, disease management, and care management initiatives
Support Humana values and the enterprise social needs team mission
Provide coverage within the cluster for vacations, weekends, and holidays as needed
Report directly to the Cluster Lead Medical Director

Requirements

What you’ll need

Doctor of Medicine or Doctor of Osteopathy
Board-certified in an AOABPS or ABMS recognized medical specialty
Current and unrestricted license at the offer stage in at least one state in the assigned cluster
Ability to obtain licenses without conditions in the other cluster states based on assigned region: Indiana, Ohio, Kentucky, Virginia, Wisconsin, and Illinois
Able to satisfy onboarding requirements
At least five years of experience post-training providing clinical services
Experience in utilization management review and case management in a health plan setting
No current sanction from Federal or State Governmental organizations
Able to pass credentialing requirements
Experience working with Medicaid enrollees, providers, and stakeholders in a clinical or administrative setting
Experience with accreditation process (NCQA)
Experience with CGX and MHK
Licensure through the Interstate Medical Licensure Compact (IMLC)
Typical availability Monday-Friday, starting no later than 9am EST, with flexibility depending on business needs
Home internet with minimum download speed of 25 Mbps and upload speed of 10 Mbps
Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

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
Self-provided internet service for home or hybrid home/office employees
Occasional travel to Humana offices for training or meetings