Medical Director – Medicare Pharmacy

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

📋 Description

• Evaluate Medicare Part D and Part B drug appeals.

• Assess cases of moderate to high complexity by utilizing Medicare regulations, Humana policies, medical necessity guidelines, CMS regulations, coverage decisions, acknowledged compendia, clinical literature, as well as pharmacy policies and procedures.

• Work in tandem with clinicians and support personnel to deliver optimal value-based care for Humana members.

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

• Conduct computer-based coverage evaluations using both inter- and intra-departmental resources.

• Assist with additional duties as required in alignment with Medicare and Humana policies.

• Travel occasionally to Humana offices for training sessions or meetings.

⛳️ Requirements

• MD or DO degree.

• Active and unrestricted license in at least one jurisdiction, with a willingness to obtain additional licenses if necessary.

• Current and ongoing Board Certification, ideally in Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation.

• No existing sanctions from Federal or State Governmental entities.

• Capability to meet credentialing requirements.

• Exceptional verbal and written communication abilities.

• Strong analytical and interpretation skills.

• Previous experience working in teams aimed at quality management, utilization management, or similar endeavors.

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

• Preferred: Experience in utilization management within Medicare Advantage, managed Medicaid, or Commercial health insurance.

• Preferred: Over 5 years of direct clinical patient care experience after residency or fellowship.

• Preferred: Experience dealing with a Medicare-type population.

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

• Preferred: Exposure to Public Health, Population Health, analytics, and business metrics.

• A minimum home internet speed of 25 Mbps download and 10 Mbps upload.

• Ability to work from a dedicated space without ongoing interruptions to safeguard PHI/HIPAA information.

🏝️ Benefits

• Paid time off.

• 401(k) retirement savings plan.

• Employee assistance program.

• Business travel and accident benefits.

• Company-provided telephone equipment for Home or Hybrid Home/Office employees.

• Bi-weekly internet expense reimbursement for employees who reside and work from Home in California, Illinois, Montana, or South Dakota.

• Flexible/variable weekly hours for the part-time seasonal position.