Become a part of our caring community and help us put health first The Medical Director relies on medical background and reviews health claims. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Medical Director uses their medical background, experience, and judgement to make determinations whether they will authorize requested services, request level of care, and requested site of service. All work occurs with a context of regulatory compliance. Diverse resources, including national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise, assist work. Medical Directors will learn Medicaid requirements, and will understand how to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios. The work also includes review of all submitted clinical records, prioritization of daily work, and communication of decisions to internal associates. Additionally, the Medical Director may participate in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. Have discussions with external physicians by phone to gather additional clinical information or discuss determinations, and in some instances, these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups. This supports regional market priorities, which may include understanding Humana processes. Additionally, the focus is on collaborative business relationships, values-based care, population health, or disease or care management. Use your skills to make an impact Responsibilities The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. You support and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed. Enjoy working in a structured environment with expectations for consistency in thinking and authorship. Exercise independence in meeting departmental expectations and meets compliance timelines. Required Qualifications MD or DO degree 5+ years of direct clinical patient care experience post residency or fellowship. This experience preferably includes some time in an inpatient environment and care of a Medicaid type population, such as the disabled or those over 65 years of age. Current and ongoing Board Certification an approved ABMS/AOA Medical Specialty No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements. Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and home health or post-acute services such as inpatient rehabilitation. Managed Medicaid or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management. A current and unrestricted license in Florida and willing to obtain licensure in South Carolina and Georgia, and additional license. Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. Experience with national guidelines such as MCG® or InterQual Internal Medicine, Family Practice, Geriatrics, Hospitalist, and Emergency Medicine clinical specialists Advanced degree such as an MBA, MHA, MPH Exposure to Public Health, Population Health, analytics, and use of business metrics. Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health. The curiosity to learn, the and the courage to innovate Additional Information Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May also contribute to grievance and appeals reviews. May participate on project teams or organizational committees. #physiciancareers Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $223,800 - $313,100 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 03-06-2026 About us Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.