Medical Director-Payment Integrity

Become a part of our caring community and help us put health first

The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and / or requested site of service should be authorized at the Inpatient level. All work occurs within a context of regulatory compliance, and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources. Medical Directors will learn Medicare, Medicaid, and Medicare Advantage 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, review of all submitted clinical records, prioritization of daily work and communication of decisions to internal associates. The clinical scenarios predominantly arise from inpatient or post-acute care environments. A remote possibility exists of doing peer-to-peer discussions with an external provider. Some roles include an overview of coding practices and clinical documentation, dispute / grievance and appeals processes, and outpatient services and equipment, within their scope.

Medical Directors support Humana values, and Humana's mission, throughout all activities.

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. The ideal candidate supports and collaborates with other team members, other departments, Humana colleagues and the Lead Medical Director. After completion of mentored training, daily work is performed with minimal direction. Enjoys working in a structured environment with expectations for consistency in thinking and authorship. Exercises independence in meeting departmental expectations and meets compliance timelines.

Supports the assigned work with respect to market-wide objectives and community relations as directed.

Required Qualifications

MD or DO degree

5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes experience in an inpatient environment and / or related to care of a Medicare type population (disabled or >

65 years of age).

Current and ongoing Board Certification an approved ABMS Medical Specialty

A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required.

No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.

Excellent verbal and written communication skills.

Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and / or home health or post-acute services such as inpatient rehabilitation.

Preferred Qualifications

Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and / or Commercial products, or other Medical management organizations, hospitals / Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.

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, Hospitalist, Family Practice, Geriatrics, Emergency Medicine clinical specialists

Advanced degree such as an MBA, MHA, MPH

Exposure to Public Health, Population Health, analytics, and use of business metrics.

The curiosity to learn, the flexibility to adapt and the courage to innovate

Additional Information

Typically reports to a Lead Medical Director. The Medical Director conducts post-service, inpatient care reviews for accurate billing of clinically valid diagnoses and care received. May also engage in disputes and 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 : 02-28-2026

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.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https : / / www.humana.com / legal / accessibility-resources?source=Humana_Website.