Medical Director – Medicare Pharmacy

🔥 15 hours ago

🇺🇸 United States – Remote

💵 $223.8k - $313.1k / year

⏱ Part Time

🔴 Lead

👨‍⚕️ Medical Director

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • 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.

📋 Description

• Review Medicare Part D and Part B drug appeals • Analyze moderately complex to complex cases using Medicare rules, Humana policies, and medical necessity criteria • Collaborate with clinicians and support staff to provide Humana members with optimal value-based care • Apply CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature • Learn Medicare Part D and Medicare Advantage requirements and operationalize them in daily work • Conduct computer-based coverage reviews for drug appeals • Use inter- and intra-departmental resources • Perform other responsibilities as necessary to support value-based care in accordance with Medicare and Humana policy • Travel occasionally to Humana offices for training or meetings

🎯 Requirements

• MD or DO degree • A current and unrestricted license in at least one jurisdiction and willingness to obtain additional license, if required • Current and ongoing Board Certification, with preference for Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation • No current sanction from Federal or State Governmental organizations • Able to pass credentialing requirements • Excellent verbal and written communication skills • Evidence of analytic and interpretation skills • 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 • Utilization management experience in a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial health insurance • 5+ years of direct clinical patient care experience post residency or fellowship, preferably including experience related to a Medicare-type population • Experience with national guidelines such as MCG, InterQual, NCCN, Micromedex, Lexicomp, and Elsevier's Clinical Pharmacology • Exposure to Public Health, Population Health, analytics, and use of business metrics • Experience functioning as a team member, providing support to reach a common goal • Minimum home internet speed of 25 Mbps download and 10 Mbps upload • Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Paid time off • 401(k) retirement savings plan • Employee assistance program • Business travel and accident benefits • Internet expense payment for employees who live and work from home in California, Illinois, Montana, or South Dakota • Telephone equipment appropriate to meet business requirements • Remote work arrangement • Flexible/variable weekly hours

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