Medical Director -Pharmacy Appeals

Humana

1d • $223,800 - $313,100 • Remote

About The Position

The Medical Director uses broad clinical expertise to review Medicare Part D and Part B drug appeals. The role handles moderately complex to complex cases requiring case-by-case analysis of Medicare rules, Humana policies, and medical necessity. Reviews are computer-based and draw on internal resources and applicable clinical and regulatory references, including CMS policies, National and Local Coverage Determinations, CMS-recognized compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature.

The Medical Director collaborates with clinicians and support staff to provide Humana members with value-based care in accordance with Medicare requirements and Humana policy. Work may include peer-to-peer discussions with prescribers, participation in Administrative Law Judge hearings, support for CMS audits, and cross-functional team activities. The role operates within regulatory compliance requirements and involves learning Medicare Part D and Medicare Advantage requirements and applying them in daily work.

This is a remote position with occasional travel to Humana offices for training or meetings. Employees must have a dedicated workspace that protects member PHI/HIPAA information and meet the stated home internet requirements. Scheduled hours are 40 per week.

Requirements

• MD or DO degree.
• At least 5 years of direct clinical patient-care experience after completion of doctorate; experience with Medicare-type populations (people with disabilities or those over age 65) is preferred.
• Current and ongoing board certification; preferred specialties include Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation.
• Current, unrestricted physician license in at least one jurisdiction and willingness to obtain additional licensure if required.
• No current sanctions from federal or state governmental organizations and ability to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Analytical and interpretation skills, with prior participation in teams focused on quality management, utilization management, or similar activities.

Nice To Haves

• Knowledge of managed care, 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.
• Experience with national guidelines or references such as MCG, InterQual, NCCN, Micromedex, Lexicomp, or Elsevier's Clinical Pharmacology.
• Exposure to public health, population health, analytics, and business metrics.
• Curiosity to learn, flexibility to adapt, and courage to innovate.
• Experience functioning as a team member and supporting a common goal.

Responsibilities

• Review moderately complex to complex Medicare Part D and Part B drug appeals for coverage, applying Medicare rules, Humana policies, and medical-necessity criteria.
• Use applicable CMS policies, coverage determinations, recognized compendia, Humana pharmacy policies and procedures, clinical literature, and other resources in case reviews.
• Collaborate with clinicians and support staff to provide members with value-based care in accordance with Medicare requirements and Humana policy.
• Conduct peer-to-peer discussions with prescribers as needed.
• Participate in hearings involving an Administrative Law Judge.
• Support CMS audits.
• Participate in cross-functional team activities and perform other responsibilities needed to support value-based care and policy compliance.
• Learn Medicare Part D and Medicare Advantage requirements and apply them in daily work.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, company holidays, and personal holidays.
• Paid parental and caregiver leave.
• Short-term and long-term disability coverage.
• Life insurance.
• Bonus incentive plan.
• Internet expense payment every two weeks for eligible employees who live and work from home in California, Illinois, Montana, or South Dakota.
• Telephone equipment appropriate to the position's business requirements.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree