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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.

Join a collaborative team of physicians who bring clinical expertise to medical necessity review and help ensure members receive appropriate, guideline‑aligned inpatient care. This role is ideal for physicians who enjoy thoughtful case analysis, structured decision-making, and working within a supportive medical team—without the physical demands or unpredictable hours of bedside care. This job is also ideal for Hospitalists, Intensivists, Emergency Physicians, and Physicians with Inpatient or Utilization Review Experience

Role Overview

• Provide expert clinical review of inpatient medical records and determine medical necessity based on national guidelines, CMS requirements, Humana policies, and clinical standards.
• Synthesize complex hospital-based cases and deliver clear, well‑reasoned determinations.
• Engage external providers by phone to gather clinical information and discuss decisions.
• Work in a structured, team‑based environment that values consistency, integrity, and professional collaboration.
• Support Humana’s mission through high‑quality decision-making and strong physician partnerships.

Key Responsibilities

• Conduct timely, compliant inpatient medical necessity reviews.
• Maintain performance standards for productivity, quality, accuracy, and turnaround times.
• Communicate determinations clearly in both verbal and written formats.
• Participate in rotational weekend/holiday coverage (approx. 5 weekends per year).
• Adapt to evolving workflows, tools, and utilization management practices.

Use your skills to make an impact
 

Required Qualifications

• MD or DO with 5+ years of post‑residency clinical experience, preferably with inpatient exposure (hospitalist-level acuity, ED, ICU, or hospital-based FP/IM).
• Active, unrestricted medical license in at least one state; willing to obtain additional licenses if needed.
• Current and ongoing Board Certification in an approved AOABPS or ABMS Medical Specialty
• Strong analytical, communication, and documentation skills.
• Meets credentialing standards with no state or federal sanctions.
• Comfortable working within a structured environment and collaborating across teams.

Preferred Qualifications

• Prior utilization management or inpatient review experience (Medicare Advantage, Managed Medicaid, Commercial).
• Familiarity with MCG® or InterQual®.
• Experience caring for Medicare populations and working within hospitals, IDNs, or medical management organizations.
• Flexible, curious, and able to adapt to workflow, regulatory, or system changes.
• Facility with clinical technology and commitment to efficiency and innovation.
• Interest in contributing to educational content, teaching, or team learning initiatives.
• Passion for supporting consistent outcomes, excellent consumer experiences, and a highly engaged team culture.

Additional Information

• Reports to a Lead Medical Director.
• Shift: Standard Monday-Friday EST hours with quarterly weekend rotations
• May participate in organizational committees or project teams.

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