Medical Director – Pharmacy Appeals

2 days ago

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Humana

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Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

10,000+ employees

Founded 1961

⚕️ Healthcare Insurance

📋 Description

• The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B) • Collaborate with clinicians and support staff to provide Humana members with optimal value based care in accordance with Medicare and Humana policy • Participate in hearings involving an Administrative Law Judge • Support for CMS audits • Cross-functional team activities • Computer based review of moderately complex to complex appeals for coverage for drugs using resources outlined above

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience related to a Medicare type population (disabled or >65 years of age) • A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required • No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements • Excellent verbal and written communication skills • Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, or similar activities • Knowledge of the managed care industry, Integrated Delivery Systems, health insurance, or clinical group practice management (preferred) • Utilization management experience in a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial health insurance (preferred) • Current and ongoing Board Certification in Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation (preferred) • Experience with national guidelines, such as MCG, InterQual, NCCN, Micromedex, Lexicomp, Elsevier’s Clinical Pharmacology (preferred) • Exposure to Public Health, Population Health, analytics, and use of business metrics (preferred) • Curiosity to learn, flexibility to adapt, courage to innovate (preferred) • Experience functioning as a Team member, providing support to reach a common goal (preferred)

🏖️ Benefits

• 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 • many other opportunities