Pharmacy Appeals Lead Medical Director

Humana

3d • Remote

About The Position

Become a part of our caring community and help us put health first Position Summary The Pharmacy Appeals Lead Medical Director is a dual focused role that combines clinical case production with protected administrative leadership time. This leader will oversee the operational and clinical excellence of the VSP Physician Program and serve as a key clinical partner across appeals, audits, and pharmacy operations. The ideal candidate is motivated, collaborative, clinically astute, and committed to continuously improving processes while keeping member impact at the forefront of every decision. ________________________________________ Candidate Attributes A successful candidate will: Be highly motivated and accountable. Thrive in a collaborative, team-oriented environment. Think creatively about operational and clinical improvements. Approach work with a strong member-first perspective. Demonstrate exceptional clinical judgment and analytical reasoning.

Requirements

• MD or DO with active, unrestricted medical license.
• Strong clinical acumen with experience interpreting complex medical and pharmacy evidence.
• Prior experience in utilization management, appeals, audit, or clinical operations preferred.
• Demonstrated ability to lead teams, mentor physicians, and manage performance.
• Creative problem‑solver with a continuous improvement mindset.
• Strong communication skills and ability to collaborate across multi‑disciplinary teams.

Responsibilities

• Oversee and supervise the VSP Physician Program, ensuring high-quality performance across: Quality review Hiring and onboarding Training and skill development Midyear performance evaluation Workforce management (WFM) Productivity metric design and monitoring Escalated clinical guidance
• Field and respond to AllMed Clinical Questions, ensuring timely and accurate clinical guidance.
• Serve as a clinical SME for the Core Physician and Pharmacist Appeals Teams, providing support on complex clinical questions and partnering to develop more efficient workflows.
• Function as a trainer for new hires within the Core Physician Appeals Teams.
• Participate in audit activities as both a researcher and a team oversight lead, ensuring accuracy, readiness, and strong clinical rationale in audit response materials.
• Support IRE OT/ALJ processes on behalf of VSP physicians, including case review guidance and clinical rationalization.

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

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