Medical Director - OP Medicare

Become a part of our caring community   The Medical Director, National Outpatient Medicare leverages clinical expertise and medical judgment to review preauthorization requests for services. This role is responsible for evaluating moderately complex to complex cases, where analysis of clinical information and situational factors requires in-depth assessment and sound decision-making. As a Medical Director at Humana , you will use your clinical expertise and judgment to make meaningful coverage and care determinations that support quality, consistency, and compliance across the healthcare continuum. In this role, you will review requests for services, level of care, and site of service, using nationally recognized clinical guidelines, CMS policies, medical references, and internal clinical resources to guide decision-making. This position offers the opportunity to work on complex outpatient cases , review clinical documentation, and collaborate with both internal partners and external physicians to gather additional information and discuss determinations. You may also contribute to care management activities and, depending on the role, provide input on areas such as clinical documentation, coding, grievances and appeals, and outpatient services or equipment reviews. Beyond case review, this role provides the opportunity to build strong relationships with physicians, provider groups, facilities, and community partners in support of regional priorities. It is a strong fit for physicians who are interested in contributing to value-based care, population health, and care management strategies while working in a structured environment that values sound clinical judgment, collaboration, and operational excellence. Humana is seeking a Medical Director to apply clinical expertise and judgment in reviewing complex outpatient cases, making coverage determinations, and supporting high-quality, compliant utilization management practices. This role offers the opportunity to collaborate with physicians and cross-functional partners, contribute to care management and appeals-related activities, and help advance Humana’s focus on value-based care, population health, and improved health outcomes . Use your skills to make an impact   Responsibilities Use clinical expertise, medical judgment, and experience to determine authorization for requested services, level of care, and site of service. Perform medical necessity and coverage reviews in compliance with regulatory standards, CMS requirements, Medicare and Medicare Advantage guidelines, clinical criteria, Humana policies, and contractual obligations. Conduct computer-based review of moderately complex to complex clinical cases, primarily involving outpatient care, using submitted clinical documentation and records to support accurate, evidence-based determinations. Evaluate whether services rendered by healthcare professionals align with national guidelines, clinical standards, CMS requirements, and internal policies. Prioritize and manage daily case review workload to ensure timely completion and adherence to compliance-driven turnaround times. Communicate utilization review decisions and clinical determinations to internal associates and other relevant stakeholders. Collaborate with external physicians to obtain additional clinical information, discuss determinations, support peer-to-peer reviews, and apply conflict resolution skills when needed during adverse determination discussions. Participate in care management activities, when applicable, to support quality outcomes, care coordination, and appropriate resource utilization. Provide oversight or input, as applicable, regarding coding practices, clinical documentation, grievance and appeals processes, and outpatient services and equipment reviews. Collaborate with internal team members, cross-functional partners, Humana colleagues, and regional health services leadership to support organizational, market, and regional goals. Engage with contracted physicians, physician groups, facilities, and community organizations, and contribute to value-based care, population health, disease management, and care management initiatives. Work independently in a structured environment after mentored training, exercising sound judgment with minimal direction and meeting departmental expectations for quality, consistency, productivity, documentation, and compliance timelines. Required Qualifications MD or DO degree 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an outpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age). Current and ongoing Board Certification in 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, with a professional and responsive approach. Demonstrated analytical and interpretive skills, with the ability to evaluate information and make informed judgments. A strong desire to learn, flexibility to adapt to change, and the courage to innovate and improve processes. Preferred Qualifications Knowledge of the managed care industry, including Medicare Advantage and Managed Medicaid. Utilization management experience in a medical management review organization, including Medicare Advantage, Managed Medicaid, or Commercial health insurance. Experience applying national clinical guidelines such as MCG® or InterQual . Advanced degree preferred, such as an MBA, MHA, or MPH . Exposure to Public Health , Population Health , analytics, and business metrics. Experience collaborating with Case Managers or Care Managers on complex case management, including familiarity with social