Medical Director - OneHome

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The Medical Director evaluates the medical necessity of healthcare services, ensuring decisions comply with regulatory and organizational standards. The role requires interpreting clinical guidelines, CMS policies, and Medicare requirements, and applying them consistently. All work at OneHome is conducted within a framework of regulatory compliance. This secures compliance with all requirements set by federal and state laws. Medical Directors review clinical cases for Medicare and Medicaid members, report to the Lead Medical Director, and work within defined timelines and departmental expectations.

Role Responsibilities:

• Review clinical cases and determine medical necessity of services for Medicare and Medicaid members
• Ensure compliance with review policies, procedures, and regulatory standards
• Apply clinical guidelines, CMS policies, and Medicare/Medicare Advantage/Medicaid requirements
• Identify opportunities for medical management operational improvements
• Participate in call rotations, including weekend coverage and after-hours coverage
• Contribute to an engaged, collaborative team culture that supports organizational excellence
• Deliver exceptional consumer experiences
• Support Home Solutions and other activities as assigned by the OneHome leadership

Use your skills to make an impact

Required Qualifications

• MD or DO degree
• Current, active and ongoing board certification from the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialties (AOABPS). National Board of Physicians & Surgeons (NBPAS) certification is not accepted
• Current and unrestricted state license in at least one state and willing to obtain other medical licenses, as required, for various states in region of assignment
• No sanctions from Federal or State Governmental organizations
• 5 years of direct clinical patient care experience post residency or fellowship
• The ability to pass credentialing requirements
• Intermediate to advanced skills utilizing Microsoft Office and Internet navigation
• Strong verbal and written communication skills, with the ability to analyze information and interpret data clearly and accurately
• Adaptable and willing to learn new technologies to enhance workflow efficiency

Preferred Qualifications

• Experience in an inpatient and/or outpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age)
• Internal Medicine, Family Practice, Geriatrics, Physiatry, Emergency Medicine, Critical Care, Surgery or hospital based clinical specialists

Additional Information

• Workstyle: remote work at home
• Hours: Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM, call rotations, including weekend coverage and after-hours coverage
• Training: 10 weeks of onboarding, no time off and training is in Eastern Standard Time (EST)

Work At Home Guidance

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 required.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Humana will provide Home or Hybrid Home/Office employees 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.

Scheduled Weekly Hours

Pay Range

Description of Benefits

About us

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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.