Corporate MD Grievance & Appeals

Humana

1d•$246,100 - $344,200•Remote

About The Position

The Corporate Medical Director uses medical expertise and medical record reviews to make appeals decisions. The role provides clinical interpretation and determinations about the appropriateness, necessity, and quality of services delivered by other healthcare professionals, following established review policies, procedures, regulatory requirements, and performance standards. The position handles complex matters using independent judgment and critical analysis, and serves as a clinical subject matter expert for grievance and appeal cases involving Medicare, Medicaid, and Commercial products. The role performs or oversees clinical reviews for assigned markets, member populations, or condition-specific areas; provides clinical expertise on home health, rehabilitation, inpatient, outpatient, and transitional care services; and partners with cross-functional teams to improve consistency, timeliness, compliance, and member-centered decisions. It also contributes to initiatives that improve member experience and reduce preventable escalations, and maintains awareness of applicable regulations, accreditation standards, and medical policy changes. This is a fully remote position for someone living in the USA. Occasional travel to Humana offices, meetings, training, or conferences may be required. Typical work hours are Monday through Friday, eight hours per day, with some flexibility depending on business needs; holiday and weekend coverage may be required. The position requires a dedicated home workspace that protects member PHI/HIPAA information and internet service with at least 25 Mbps download and 10 Mbps upload speeds. Scheduled weekly hours are 40. The stated starting base pay range is $246,100–$344,200 per year, with individual pay varying based on location and job-related qualifications. The position is eligible for a bonus incentive plan. Humana offers medical, dental, and vision benefits; a 401(k) plan; paid time off and company/personal holidays; paid parental and caregiver leave; short- and long-term disability; life insurance; and other benefits.

Requirements

MD or DO degree.
Current and unrestricted license in at least one jurisdiction, with ability and willingness to obtain a license without conditions as required for various states in the assigned region.
No current sanction from Federal or State Governmental organizations and ability to pass credentialing requirements.
Board certified in an approved ABMS medical specialty.
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 specialization 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 issues involving 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 to improve member experience and reduce preventable escalations or dissatisfaction.
Provide expertise across relevant clinical specialties, including Internal Medicine, Family Practice, Geriatrics, and Hospital Medicine.
Support holiday or after-hours coverage as required to maintain regulatory and operational review timelines.
Maintain awareness of emerging regulations, accreditation standards, and medical policy changes affecting grievance and appeal determinations.