Medical Director – Pharmacy Appeals

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

📋 Description

• Evaluate Medicare drug appeals for both Part D and Part B coverage.

• Assess moderately complex to highly complex cases in accordance with Medicare regulations, Humana policies, medical necessity standards, CMS guidelines, coverage determinations, recognized compendium, clinical protocols, and published literature.

• Perform computer-based evaluations of drug coverage appeals.

• Engage in peer-to-peer discussions with prescribing physicians.

• Take part in hearings with an Administrative Law Judge.

• Assist in supporting CMS audits.

• Work collaboratively with clinicians, support personnel, and both inter- and intra-departmental resources.

• Be involved in cross-functional team initiatives.

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

• Promote optimal value-based care in alignment with Medicare and Humana policies.

⛳️ Requirements

• MD or DO degree required.

• At least 5 years of direct clinical patient care experience following the completion of the doctoral program.

• Ideally, some experience with a Medicare-type population (those who are disabled or over 65 years of age).

• Current and active Board Certification is necessary, preferably in Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation.

• Must hold a current and unrestricted physician license in at least one jurisdiction.

• Willingness to obtain an additional license if necessary.

• No existing sanctions from Federal or State governmental entities.

• Must be capable of meeting credentialing requirements.

• Strong verbal and written communication skills are essential.

• Demonstrated analytical and interpretive abilities are required.

• Previous experience in teams focused on quality management, utilization management, or related activities is preferred.

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

• Experience in utilization management within Medicare Advantage, managed Medicaid, or commercial health insurance is a plus.

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

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

• A strong desire to learn, adaptability to change, and a willingness to innovate are essential traits.

• Experience working as part of a team to achieve shared objectives is necessary.

• A minimum internet speed of 25 Mbps for download and 10 Mbps for upload is required for home or hybrid remote work.

• Must have the ability to work from a dedicated space free from ongoing interruptions to safeguard member PHI/HIPAA information.

🏝️ Benefits

• Bonus incentive plan based on both company and individual performance.

• Comprehensive medical, dental, and vision benefits.

• 401(k) retirement savings program.

• Paid time off.

• Company holidays and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability coverage.

• Life insurance.

• Telephone equipment provided as per business needs.

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