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, medical necessity criteria, CMS policies, coverage determinations, recognized compendia, clinical literature, and pharmacy policies and procedures • Collaborate with clinicians and support staff to provide Humana members with optimal value-based care • Learn Medicare Part D and Medicare Advantage requirements and operationalize them in daily work • Perform computer-based coverage reviews using inter- and intra-departmental resources • Support additional responsibilities as necessary in accordance with Medicare and Humana policy • Occasionally travel to Humana offices for training or meetings

🎯 Requirements

• MD or DO degree • Current and unrestricted license in at least one jurisdiction and willingness to obtain additional license, if required • Current and ongoing Board Certification, preferably in Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation • No current sanction from Federal or State Governmental organizations • Ability to pass credentialing requirements • Excellent verbal and written communication skills • Analytic and interpretation skills • Prior experience participating in teams focused on quality management, utilization management, or similar activities • Preferred: Knowledge of managed care, Integrated Delivery Systems, health insurance, or clinical group practice management • Preferred: Utilization management experience in Medicare Advantage, managed Medicaid, or Commercial health insurance • Preferred: 5+ years of direct clinical patient care experience post residency or fellowship • Preferred: Experience related to a Medicare-type population • Preferred: Experience with 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 • Minimum home internet speed of 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions to protect 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 payment for employees who live and work from Home in California, Illinois, Montana, or South Dakota • Flexible/variable weekly hours for the part-time seasonal position