Medical Director – Medicare Pharmacy, VSP

Humana

5d•$223,800 - $313,100•Remote

About The Position

The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments involve moderately complex to complex issues where the analysis of situations or data requires a case-by-case consideration of the Medicare rules, Humana policies and medical necessity. This Medical Director position is non-benefitted, and compensated hourly. The Medical Director will collaborate with clinicians and support staff to provide Humana members with optimal value-based care in accordance with Medicare and Humana policy. All work occurs within a context of regulatory compliance and work is assisted by diverse resources, included but not limited to CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature as appropriate. Medical Directors will learn Medicare Part D and Medicare Advantage requirements and will understand how to operationalize this in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex appeals for coverage for drugs using resources outlined above as well as inter- and intra-departmental resources. Work may include other responsibilities as determined necessary to support optimal value-based care in accordance with Medicare and Humana policy.

Requirements

MD or DO degree
A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
Current and ongoing Board Certification with preference for Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, or similar activities

Nice To Haves

Knowledge of the managed care industry, Integrated Delivery Systems, health insurance, or clinical group practice management
Utilization management experience in a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial health insurance
5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience related to a Medicare type population (disabled or >65 years of age)
Experience with national guidelines, such as MCG, InterQual, NCCN, Micromedex, Lexicomp, Elsevier's Clinical Pharmacology
Exposure to Public Health, Population Health, analytics, and use of business metrics
Curiosity to learn, flexibility to adapt, courage to innovate
Experience functioning as a Team member, providing support to reach a common goal

Responsibilities

Review Medicare drug appeals (Part D & B).
Analyze situations or data requiring case-by-case consideration of Medicare rules, Humana policies, and medical necessity.
Collaborate with clinicians and support staff to provide optimal value-based care.
Conduct computer-based review of appeals for drug coverage.
Perform other responsibilities as determined necessary to support optimal value-based care.