Become a part of our caring community
 

The Medical Director is responsible for Medicaid care strategy and/or operations. 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.

Responsibilities:

• Use clinical training, professional experience, and sound medical judgment to determine whether requested services, level of care, or site of service should be authorized.

• Make determinations in accordance with regulatory and compliance requirements and with support from approved resources, including national clinical guidelines, state Medicaid policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other established sources.

• Develop and maintain a working knowledge of Medicaid requirements and apply that knowledge effectively in daily work within the assigned cluster.

• Perform computer-based reviews of moderately complex to highly complex clinical cases from both outpatient and inpatient settings.

• Review all submitted clinical documentation and supporting records to determine medical necessity and appropriateness of care.

• Prioritize daily review work to meet operational expectations and turnaround requirements.

• Communicate determinations and rationale to internal associates in a timely and professional manner.

• Participate in care management-related activities, as appropriate.

• Conduct peer-to-peer discussions with external physicians by phone to obtain additional clinical information and discuss medical necessity determinations.

• Use effective communication and conflict resolution skills in peer-to-peer conversations, particularly in cases involving disagreement or escalated review.

• Collaborate with contracted physicians, physician groups, facilities, and community organizations in support of regional market priorities.

• Demonstrate knowledge of Humana processes while fostering collaborative relationships that support value-based care, population health, and disease or care management initiatives.

• Support Humana’s values and the mission of the Enterprise Social Needs team in all activities and interactions.

• Provide cross-coverage and flow to work across the assigned cluster, as needed, for vacations, weekends, and holiday coverage.

Qualifications: 

• Doctor of Medicine or Doctor of Osteopathy 

• Board-certified in ABMS recognized specialty 

• A current and unrestricted license in at least one of the states that are part of the specific cluster: IN, OH, KY, VA, WI, & IL and ability to obtain unrestricted licenses in the other cluster states that require licensure.

• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting

• Experience with accreditation process (NCQA)

• Experience with CGX and MHK

• Experience in utilization management review and case management in a health plan setting

Use your skills to make an impact
 

Reporting Relationship:

This position reports directly to the Cluster Lead Medical Director.

Location:

This role is based virtually in one of the states of the specific cluster, which includes: IN, OH, KY, VA, WI, & IL

Work Style: Fully Remote; may be required for occasional travel to onsite Humana Hubs

Work Hours:

Typical business hours are Monday-Friday, 8 hours/day, 5 days/week some flexibility might be possible, depending on business needs.

Interview Format 

As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers with an enhanced method for decision-making through on-demand candidate assessments.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions. You should anticipate the assessment to take approximately 10-15 minutes.

Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

SSN Task via Workday

Should you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

 

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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 09-22-2026

About us
 

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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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.