Medical Director – Inpatient Review

🔥 22 hours ago

🇺🇸 United States – Remote

💵 $223.8k - $313.1k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Perform expert clinical review of inpatient medical records • Assess medical necessity using national guidelines, CMS regulations, Humana policies, and recognized clinical standards • Analyze complex hospital-based cases and make utilization management determinations • Communicate with external providers by phone to obtain clinical information and discuss review outcomes • Conduct inpatient medical necessity reviews in accordance with regulatory requirements • Maintain productivity, accuracy, quality, and timely completion of assigned tasks • Communicate review outcomes clearly and professionally in verbal and written formats • Adapt to changing workflows, tools, and utilization management procedures • Collaborate in a structured, multidisciplinary team environment • Support high-quality, consistent decision-making and physician partnerships • Report directly to a Lead Medical Director • Participate in organizational committees or special project teams as needed

🎯 Requirements

• MD or DO • 5 or more years post-residency clinical experience • Active, unrestricted medical license in at least one state and willingness to obtain additional licenses as needed • Current and ongoing Board Certification in an AOABPS- or ABMS-recognized medical specialty • Meets all credentialing requirements, with no state or federal sanctions • Strong analytical, communication, and documentation skills • Ability to work effectively within a structured environment and as part of a multidisciplinary team • Inpatient exposure, including hospitalist-level acuity, ED, ICU, or hospital-based FP/IM (preferred) • Prior experience in utilization management or inpatient review (preferred) • Familiarity with MCG or InterQual guidelines (preferred) • Experience providing care for Medicare populations and working in hospitals, integrated delivery networks, or medical management organizations (preferred) • Adaptability to changes in workflow, regulatory requirements, or clinical systems (preferred) • Proficiency with clinical technology platforms (preferred) • Commitment to process improvement and innovation (preferred) • Must work standard Monday-Friday hours with rotational weekend/holiday coverage • Must meet work-from-home requirements, including minimum 25 Mbps download and 10 Mbps upload internet speeds and a dedicated workspace protecting PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental, and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Occasional travel to Humana offices for training or meetings • Remote work arrangement • Dedicated home workspace and internet requirements supporting work from home

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