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The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing Home Health, SNF, DME, dual Medicare/Medicaid, Medicaid, IRF and LTACH requests. The Medical Director reviews and determines whether healthcare services provided by other healthcare professionals align with national guidelines, CMS requirements, Humana policies, clinical standards, and applicable contracts.

The Medical Director evaluates the medical necessity of healthcare services, ensuring decisions comply with regulatory and organizational standards. The role requires interpreting clinical guidelines, CMS policies, and Medicare requirements, and applying them consistently. All work at OneHome is conducted within a framework of regulatory compliance. This secures compliance with all requirements set by federal and state laws. Medical Directors review clinical cases for Medicare and Medicaid members, report to the Lead Medical Director, and work within defined timelines and departmental expectations.

• Review clinical cases and determine medical necessity of services for Medicare and Medicaid members
• Ensure compliance with review policies, procedures, and regulatory standards
• Apply clinical guidelines, CMS policies, and Medicare/Medicare Advantage/Medicaid requirements
• Identify opportunities for medical management operational improvements
• Participate in call rotations, including weekend coverage and after-hours coverage
• Contribute to an engaged, collaborative team culture that supports organizational excellence
• Deliver exceptional consumer experiences
• Support Home Solutions and other activities as assigned by the OneHome leadership

Required Qualifications

• MD or DO degree
• Current, active and ongoing board certification from the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialties (AOABPS). National Board of Physicians & Surgeons (NBPAS) certification is not accepted
• Current and unrestricted state license in at least one state and willing to obtain other medical licenses, as required, for various states in region of assignment
• No sanctions from Federal or State Governmental organizations
• 10 years of direct clinical patient care experience post residency or fellowship
• The ability to pass credentialing requirements
• Intermediate to advanced skills utilizing Microsoft Office and Internet navigation
• Strong verbal and written communication skills, with the ability to analyze information and interpret data clearly and accurately
• Adaptable and willing to learn new technologies to enhance workflow efficiency
• Participate in educational activities by attending required conferences and creating content to present for individual subject matter contribution

• Experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
• Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, Surgery or hospital based clinical specialists
• Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual

• Workstyle: remote work at home
• Hours: Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM, call rotations, including weekend coverage and after-hours coverage
• Training: 10 weeks of onboarding, no time off and training is in Eastern Standard Time (EST)

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

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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.

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.

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.

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.