Corporate MD Grievance & Appeals

Humana

5d•$246,100 - $344,200•Remote

About The Position

The Corporate Medical Director uses medical expertise and medical-record reviews to make clinical determinations for grievance and appeal cases. The role addresses problems of diverse scope and complexity, applying independent judgment and critical analysis to determine the appropriateness, necessity, and quality of healthcare services delivered by other professionals. Determinations must follow established review policies, procedures, regulatory requirements, and performance standards. The position serves as a clinical subject matter expert on complex matters involving Medicare, Medicaid, and Commercial products, and provides expertise across services such as home health, rehabilitation, inpatient, outpatient, and transitional care. The role supports assigned markets, member populations, or condition-specific areas and partners with cross-functional teams to improve consistency, compliance, turnaround times, and member-centered decisions. It also contributes to efforts to improve the member experience and reduce preventable escalations, while maintaining awareness of changing regulations, accreditation standards, and medical policies. This is a fully remote position for someone living in the contiguous United States. Occasional travel to Humana offices for training or meetings may be required, and very minimal travel may be needed for conferences. Typical hours are Monday through Friday, 8 a.m. to 5 p.m., with some flexibility depending on business needs. Holiday, weekend, and after-hours coverage may be required to meet business needs and regulatory or operational review timelines. The position is scheduled for 40 hours per week.

Requirements

MD or DO degree.
Current, unrestricted licensure in at least one jurisdiction, with the ability and willingness to obtain additional unrestricted licenses for states within the assigned region as needed.
No current sanction from Federal or State Governmental organizations and ability to pass credentialing requirements.
Board Certified in an approved ABMS Medical Specialty.
Prompt and professional written and verbal communication skills.
Five years of established clinical experience post residency.
Knowledge of the managed care industry, including Medicare, Medicaid, and/or Commercial products.
Passion for contributing to an organization focused on continuously improving consumer experiences.

Nice To Haves

Medical utilization management experience in Medicare Advantage (MA) Grievances and Appeals.
Experience working with health insurance organizations, hospitals, other healthcare providers, and/or patients.
Clinical specialty experience in Internal Medicine, Family Practice, Geriatrics, Hospitalist medicine, Anesthesiology, Physical Medicine and Rehabilitation, Emergency Medicine, Neurology, or General Surgery.

Responsibilities

Provide medical interpretation and clinical judgment regarding the appropriateness, necessity, and quality of services rendered by other healthcare professionals.
Perform or oversee clinical reviews of grievance and appeal cases for assigned markets, member populations, or condition-specific areas.
Ensure determinations comply with medical review policies, regulatory requirements, internal procedures, and performance standards.
Serve as a clinical subject matter expert for complex grievance and appeal matters involving Medicare, Medicaid, and Commercial products.
Make independent decisions on highly complex clinical issues, including cases with variable factors, incomplete information, or competing clinical considerations.
Act as a clinical resource for home health, rehabilitation, inpatient, outpatient, and transitional care services.
Ensure reviews reflect knowledge of managed care operations and Medicare, Medicaid, and Commercial line-of-business requirements.
Partner with cross-functional teams to improve consistency, turnaround times, compliance, and member-centered decision-making.
Contribute to initiatives that improve the member experience and reduce preventable escalations or dissatisfaction.
Provide expertise across relevant clinical specialties, including Internal Medicine, Family Practice, Geriatrics, and Hospital Medicine.
Support holidays and weekends as required by business needs and provide after-hours coverage as needed to maintain regulatory and operational review timelines.
Maintain awareness of emerging regulations, accreditation standards, and medical policy changes affecting grievance and appeal determinations.