Medical Director National OP - Medicare
$223.8k - $313.1k/yr+ Bonus incentive plan
Senior
MBA, MD
Remote in USA
RemoteRemote work is limited to the contiguous United States.
Medical, Clinical & VeterinaryPhysicians & Surgeons
About the job
Requirements
- An MD or DO degree is required.
- At least 5 years of direct clinical patient-care experience after residency or fellowship is required; inpatient experience or experience with Medicare-type populations is preferred within this requirement.
- Current and ongoing board certification in an approved American Board of Medical Specialties medical specialty is required.
- A current, unrestricted license in at least one jurisdiction is required, with willingness to obtain additional licensure if needed.
- Candidates must have no current sanctions from federal or state governmental organizations and must be able to pass credentialing requirements.
- Strong verbal and written communication skills are required.
- Analytic and interpretation skills are required.
- Candidates must be able to meet departmental expectations independently, work in a structured environment, and consistently produce written determinations.
- Candidates must meet compliance timelines consistently.
- Candidates must be able to work from a dedicated home workspace without ongoing interruptions to protect member protected health information, and provide internet service with at least 25 Mbps download and 10 Mbps upload speeds.
Responsibilities
- Review preauthorization requests and submitted clinical records, and use medical judgment to determine whether requested services, levels of care, and sites of service should be authorized.
- Conduct utilization management of care received by members in an assigned market, member population, or condition type.
- Interpret medical information and determine whether services delivered by other healthcare professionals align with national guidelines, Centers for Medicare & Medicaid Services requirements, Humana policies, clinical standards, and applicable contract requirements.
- Prioritize daily clinical-review work, communicate decisions to internal associates, and meet applicable compliance timelines.
- Discuss cases with external physicians by phone to gather additional clinical information or discuss determinations, including resolving conflicts when necessary.
- Collaborate with team members, other departments, Humana colleagues, and the Regional Vice President of Health Services.
- Participate in care management, grievance and appeals reviews, project teams, or organizational committees as applicable.
- Support contracted external physicians, physician groups, facilities, and community groups on regional market priorities, including collaborative business relationships, value-based care, population health, disease management, or care management, as applicable.
- Complete daily responsibilities with minimal direction after mentored training.
Desired Qualifications
- Experience that includes inpatient care or care related to a Medicare-type population, including disabled people or people over age 65.
- Knowledge of the managed-care industry, including Medicare Advantage and Managed Medicaid.
- Utilization-management experience in a medical-management review organization, such as Medicare Advantage, managed Medicaid, or commercial health insurance.
- Experience with national guidelines such as MCG or InterQual.
- An advanced degree such as an MBA, Master of Health Administration, or Master of Public Health.
- Exposure to public health, population health, analytics, and the use of business metrics.
- Experience working with case managers or care managers on complex case management, including familiarity with social determinants of health.
About the company
Humana sells health insurance paid for by government programs, chiefly Medicare Advantage plans that private insurers run for Americans 65 and older in place of traditional Medicare. It ranks among the largest Medicare Advantage insurers in the country and also runs Medicaid plans for low-income families in several states. Its CenterWell business operates senior primary care clinics, a mail-order pharmacy and home health services, so many members get care from a company the insurer owns. Medicare and states pay Humana a set monthly amount per member, and it keeps the difference between those payments and members' medical costs. Humana was founded in 1961 as a nursing home company and is based in Louisville, Kentucky.
Company Size
10,001+
Company Stage
IPO
Headquarters
Louisville, Kentucky
Founded
1961
Get referred to Humana
See people who can refer or advise you
Simplify's Take
What believers are saying
- Enrollment is surging: in July 2026 Humana affirmed about 25% individual Medicare Advantage membership growth for 2026.
- Owned clinics create clinical careers: CenterWell Senior Primary Care added 130,900 patients, up 27%, in early 2026.
- Medicaid is widening: Illinois chose Humana in June 2026 to run Medicaid coverage statewide.
What critics are saying
- Low quality scores cut Medicare bonuses: only 20% of Humana's members sat in 4-star or better plans for 2026.
- The insurer is shrinking to save margins: about 600,000 Medicare Advantage members got plan-closure notices in October 2026.
- Stock grants carry risk: in July 2026 Humana cut its 2026 GAAP earnings floor to $6.52 a share from $8.36.
What makes Humana unique
- Military families are a second market: Humana runs the Pentagon's TRICARE health plan across 24 eastern states and Washington, DC.
- Florida anchors the business: Humana's Medicare Advantage contracts there produced 14% of its 2025 revenue.
- Medicaid is a quiet second insurer: Humana covers over 1.54 million low-income members across 11 states.
Help us improve and share your feedback! Did you find this helpful?
Benefits
- Health Insurance
- Dental Insurance
- Vision Insurance
- Life Insurance
- Disability Insurance
- Unlimited Paid Time Off
- Paid Vacation
- Paid Parental Leave
- Short-term Disability
- Long-term Disability
- 401(k) Retirement Plan
- 401(k) Company Match