Medical Director – Pharmacy Appeals

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

📋 Description

• Evaluate Medicare drug appeals pertaining to Part D and Part B.

• Assess moderately complex to complex cases utilizing Medicare regulations, Humana policies, medical necessity standards, CMS guidelines, coverage decisions, recognized compendia, clinical literature, and departmental resources.

• Engage in peer-to-peer discussions with prescribers.

• Take part in hearings that involve an Administrative Law Judge.

• Assist with CMS audits.

• Contribute to cross-functional team initiatives.

• Collaborate with clinicians and support personnel to deliver optimal value-based care to Humana members.

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

• Conduct all activities in compliance with regulatory requirements.

• Occasionally travel to Humana offices for training or meetings.

⛳️ Requirements

• MD or DO degree is required.

• A minimum of 5 years of direct clinical patient care experience following the completion of the doctorate.

• Active and ongoing Board Certification, preferably in Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation.

• Current and unrestricted physician license in at least one jurisdiction.

• Openness to obtaining additional licensure if necessary.

• No existing sanctions from Federal or State Governmental entities.

• Capability to meet credentialing standards.

• Exceptional verbal and written communication abilities.

• Proven analytic and interpretative skills.

• Previous involvement in teams centered on quality management, utilization management, or related activities.

• 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.

• Proficient with national guidelines, including MCG, InterQual, NCCN, Micromedex, Lexicomp, and Elsevier's Clinical Pharmacology.

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

• Experience working collaboratively as part of a team.

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

• Ability to work from a dedicated environment free from ongoing interruptions to safeguard member PHI/HIPAA information.

🏝️ Benefits

• Bonus incentive plan linked to company and/or individual performance.

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays.

• Personal holidays.

• Paid parental leave.

• Paid caregiver leave.

• Short-term disability coverage.

• Long-term disability coverage.

• Life insurance policy.

• Telephone equipment suitable for business needs for Home or Hybrid Home/Office employees.

• Bi-weekly internet expense reimbursement for employees residing and working from home in California, Illinois, Montana, or South Dakota.