Medical Director Grievances & Appeals

Become a part of our caring community
 

The Corporate Medical Director relies on medical background and reviews health claims. You will work on problems of diverse scope and complexity ranging from moderate to substantial.

The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. You exercise independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action.

Schedule is Monday-Friday with intermittent weekends

Responsibilities

• Provide clinical interpretation and determinations on the medical appropriateness of services delivered by healthcare professionals, including the application of evidence-based guidelines.

• Make independent, timely, and defensible medical decisions on complex appeal cases, exercising professional judgment with minimal supervision.

• Collaborate with cross-functional teams—including legal, compliance, and clinical operations—to address and resolve grievances and appeals.

• Participate in quality improvement initiatives, identifying trends in grievances and appeals and recommending process improvements.

• Serve as a clinical resource for grievance and appeals staff, providing guidance and education as needed.

• Maintain current knowledge of Medicare regulations, managed care requirements, and industry best practices relevant to appeals and grievances.

• Support Humana’s commitment to continuous improvement in consumer experience, ensuring fair, consistent, and customer-focused outcomes.

• Participate in internal and external audits as required and respond to regulatory inquiries as needed.

• Adhere to all confidentiality and HIPAA requirements in handling protected health information (PHI).

• Perform additional duties as assigned, including intermittent weekend work and holiday as required by the business.

Use your skills to make an impact
 

Required Qualifications

• MD or DO degree completed at an accredited university in the USA

• A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment

• Board Certified in an approved ABMS/ABOA Medical Specialty

• 5 years of established clinical experience

• Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products

• Possess analysis and interpretation skills with prior experience leading teams focusing on quality management. Experience with discharge planning and/or home health or rehab

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.

• Internal Medicine, Family Practice, Geriatrics, Hospitalist clinical specialists

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

This is a remote position anywhere in the USA

#LI-Remote

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.

$246,100 - $344,200 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 caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 11-17-2026

About us
 

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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Equal Opportunity Employer

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.