Medical Director – Medicare Pharmacy

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

📋 Description

• Evaluate appeals for Medicare Part D and Part B medications.

• Assess cases of moderate to high complexity by utilizing Medicare regulations, Humana policies, and criteria for medical necessity.

• Work collaboratively with clinicians and support staff to deliver optimal value-based care to Humana members.

• Implement CMS regulations, National and Local Coverage Determinations, recognized Compendia from CMS, NCCN guidelines, Humana Pharmacy Policies and Procedures, and clinical literature.

• Acquire knowledge of Medicare Part D and Medicare Advantage requirements and integrate them into daily operations.

• Execute computer-based evaluations for drug appeal coverage.

• Leverage inter- and intra-departmental resources effectively.

• Carry out additional responsibilities as necessary to promote value-based care in line with Medicare and Humana policies.

• Occasionally travel to Humana offices for training sessions or meetings.

⛳️ Requirements

• MD or DO degree required.

• Must possess a current and unrestricted license in at least one jurisdiction and be willing to acquire additional licenses if necessary.

• Ongoing Board Certification is essential, preferably in Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation.

• No current sanctions from Federal or State Government organizations.

• Ability to meet credentialing standards.

• Exceptional verbal and written communication abilities.

• Demonstrated analytical and interpretation skills.

• Previous experience in teams focused on quality management, utilization management, or similar initiatives.

• Familiarity with the managed care sector, Integrated Delivery Systems, health insurance, or clinical group practice management.

• Experience in utilization management within a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial health insurance.

• At least 5 years of direct clinical patient care experience following residency or fellowship, ideally with a focus on a Medicare-type population.

• Knowledge of national guidelines such as MCG, InterQual, NCCN, Micromedex, Lexicomp, and Elsevier's Clinical Pharmacology.

• Exposure to Public Health, Population Health, analytics, and the application of business metrics.

• Proven ability to function as a team member, contributing support to achieve shared objectives.

• Minimum home internet speed of 25 Mbps for downloads and 10 Mbps for uploads.

• Must work from a dedicated space free from continuous interruptions to safeguard member PHI/HIPAA information.

🏝️ Benefits

• Paid time off.

• 401(k) retirement savings plan.

• Employee assistance program.

• Business travel and accident insurance benefits.

• Internet expense reimbursement for employees working from home in California, Illinois, Montana, or South Dakota.

• Telephone equipment suitable to satisfy business needs.

• Remote work arrangement available.

• Flexible and variable weekly working hours.