Medical Director – Inpatient Review

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct comprehensive clinical evaluations of inpatient medical records.

• Evaluate medical necessity by utilizing national guidelines, CMS regulations, Humana policies, and established clinical standards.

• Analyze intricate hospital-based cases and determine utilization management outcomes.

• Engage with external providers via phone to gather clinical data and discuss the results of reviews.

• Execute inpatient medical necessity assessments in compliance with regulatory standards.

• Ensure productivity, accuracy, quality, and timely completion of all assigned responsibilities.

• Articulate review findings clearly and professionally in both verbal and written formats.

• Adapt to evolving workflows, tools, and utilization management processes.

• Collaborate effectively within a structured, multidisciplinary team environment.

• Foster high-quality, consistent decision-making and physician collaborations.

• Report directly to a Lead Medical Director.

• Engage in organizational committees or special project teams as required.

⛳️ Requirements

• MD or DO degree.

• A minimum of 5 years of clinical experience following residency.

• Active and unrestricted medical license in at least one state, with a willingness to acquire additional licenses as necessary.

• Current and continuous Board Certification in a medical specialty recognized by AOABPS or ABMS.

• Fulfillment of all credentialing standards, without any state or federal sanctions.

• Strong analytical, communication, and documentation capabilities.

• Ability to function effectively within a structured environment and as a member of a multidisciplinary team.

• Inpatient exposure, including hospitalist-level acuity, emergency department, ICU, or hospital-based family practice/internal medicine (preferred).

• Prior experience in utilization management or inpatient review (preferred).

• Familiarity with MCG or InterQual guidelines (preferred).

• Experience caring for Medicare populations and working within hospitals, integrated delivery networks, or medical management organizations (preferred).

• Adaptability to changes in workflows, regulatory demands, or clinical systems (preferred).

• Proficiency with clinical technology platforms (preferred).

• Commitment to process enhancement and innovation (preferred).

• Must adhere to standard Monday-Friday working hours with rotational weekend and holiday coverage.

• Must fulfill work-from-home criteria, including a minimum internet speed of 25 Mbps download and 10 Mbps upload, as well as a dedicated workspace that ensures the protection of PHI/HIPAA information.

🏝️ Benefits

• Bonus incentive program based on individual and/or company performance.

• Medical, dental, and vision coverage.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability insurance.

• Life insurance coverage.

• Occasional travel to Humana offices for training or meetings.

• Remote work arrangement.

• Designated home workspace and internet requirements supporting remote work.