Description

Become a part of our caring community
The Lead Medical Director relies on medical background and reviews health claims. The Lead Medical Director requires a solid understanding of how organization capabilities interrelate across department(s).

The Lead Medical Director provides clinical and operational leadership for medical review activities supporting Home Health, Skilled Nursing Facility, Durable Medical Equipment, Medicare/Medicaid dual-eligible requests, and related home care solutions. Grounded in CMS Medicare guidance and applicable regulatory requirements, this role ensures consistent, timely, fair, compliant, and evidence-based medical necessity determinations for Medicare, Medicaid, and Dual Eligible populations.

Leadership and Team Operations

• Oversee daily operations of a team of Medical Directors conducting appeals and clinical case reviews for Medicare and Dual Eligible populations.
• Maintain Medical Director staffing schedules, including paid time off, weekend coverage, after-hours coverage, and call rotation planning.
• Lead regular team meetings and cross-functional meetings with internal stakeholders, operational partners, and leadership.
• Foster development of Medical Directors through coaching, collaboration, education, and non-case review activities.
• Support team engagement and promote a collaborative culture aligned with organizational excellence and Humana's leadership expectations.
• Partner with the Director of Physician Leadership and other Lead Medical Directors to ensure consistency in processes, expectations, and performance.

Clinical Case Review and Medical Necessity Determinations

• Conduct clinical case reviews for approximately 50% of the role's responsibilities.
• Review Medicare, Medicaid, and Dual Eligible member cases to determine medical necessity and appropriateness of requested services.
• Evaluate requests related to home health, skilled nursing facility services, durable medical equipment, and other home-based care services.
• Provide clinical interpretation and medical decisions regarding services requested or provided by other healthcare professionals.
• Apply national clinical guidelines, CMS requirements, Humana policies, clinical standards, review procedures, and applicable contracts consistently.
• Identify and resolve complex clinical, technical, and operational issues that arise during case review or appeals processes.

Regulatory Compliance and Medicare Requirements

• Ensure timely completion of clinical reviews and appeals to meet Medicare regulatory requirements.
• Support compliance with CMS Medicare guidance, Medicare Advantage requirements, Medicaid requirements, and applicable federal and state laws.
• Promote consistency, accuracy, fairness, and timeliness in medical necessity determinations.
• Support team performance related to CMS Star measures, particularly Timeliness and Fairness measures.
• Ensure all clinical review work is conducted within Humana's and OneHome's regulatory compliance framework.

Cross-Functional Partnership and OneHome Support

• Develop collaborative relationships with key partners across the Medicare Line of Business, Home Care Solutions, OneHome, internal operations teams, and leadership.
• Serve as a clinical leader and subject matter resource for OneHome activities.
• Help align medical review practices with OneHome's operational model andHumana's broader Medicare and home care strategy.
• Support implementation of processes that improve service delivery, member experience, provider collaboration, and operational efficiency.
• Participate in meetings with business, clinical, operational, and compliance partners to address performance, process, and clinical review needs.

Operational Improvement and Performance Management

• Identify opportunities to improve medical management operations, workflow efficiency, review consistency, and case turnaround times.
• Support process improvement efforts related to home health, skilled nursing facility, durable medical equipment, Medicare, Medicaid, and Dual Eligible requests.
• Analyze clinical information and operational data to identify trends, risks, performance gaps, and opportunities for improvement.
• Promote workflow efficiencies through effective use of technology, systems, and standardized review practices.
• Contribute to scalable solutions that support OneHome and the evolving needs of Medicare members.

Education, Communication, and Clinical Expertise

• Participate in required educational activities, clinical conferences, and internal learning forums.
• Create and present educational content based on clinical subject matter expertise.
• Communicate clearly and professionally with Medical Directors, operational partners, leadership, and other stakeholders.
• Translate complex clinical guidelines, CMS policies, and Medicare requirements into clear guidance for consistent decision-making.
• Support knowledge-sharing across the Medical Director team to strengthen clinical review quality and consistency.

Member and Consumer Experience

• Deliver clinical decisions that support appropriate care, regulatory compliance, and a positive consumer experience
• Promote fair, timely, and evidence-based decisions for Medicare, Medicaid, and Dual Eligible members
• Help reduce unnecessary complexity in the clinical review process for members, providers, and internal partners
• Support Humana's commitment to improving access, quality, and coordination of home-based care solutions

Alignment to Humana Leadership Expectations

• Modeling customer-focused decision-making
• Simplifying complex clinical and operational processes
• Collaborating across teams and business functions
• Supporting bold, outcome-oriented improvements
• Anticipating operational needs associated with OneHome
• Promoting shared accountability across clinical, operational, and compliance teams

At Humana, we are committed to helping people achieve their best health by delivering care and service with humanity, clarity, collaboration, and accountability. Through the Humana Way, we bring our values to life by working together to create simpler, better, and faster experiences for our members, patients, teammates, and business partners.

Use your skills to make an impact

Required Qualifications

• Doctor of Medicine (MD/DO) degree from an accredited university in the USA
• Current and ongoing board certification in an approved ABMS Medical Specialty
• Active unrestricted license in at least one jurisdiction and willing to obtain additional licenses, as required, for various states in region of assignment
• 2+ years of leadership experience
• 5+ years of direct clinical patient care experience post-residency or fellowship
• No current sanction from Federal or State Governmental organizations and the ability to satisfy onboarding requirements
• There are holiday and weekend requirements for this role
• Excellent verbal and written communication skills with analytic and interpretative skills from prior experience focusing on quality, utilization, and/or case management
• Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual
• Sponsorship is not available for this role

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, inpatient and/or care of a Medicare type population (disabled or >65 years of age)
• Previous Medicare, Medicaid, and/or Commercial experience

How We Value You

• Benefits starting day 1 of employment
• Competitive 401k match
• Generous Paid Time Off accrual
• Tuition Reimbursement
• Parental Leave

Interview Process

As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making through on-demand candidate assessments.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions. You should anticipate the assessment to take approximately 10-15 minutes.

Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

SSN Task via Workday

Should you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

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.

$270,800 - $378,800 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 08-30-2026
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 atHumana.comand atCenterWell.com.

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.
Requisition #: R-422638

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