Medical Director – Pharmacy Appeals

🔥 14 hours ago

🇺🇸 United States – Remote

💵 $223.8k - $313.1k / year

⏰ Full 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 drug appeals for Part D and Part B coverage • Analyze moderately complex to complex cases using Medicare rules, Humana policies, medical necessity criteria, CMS policies, coverage determinations, recognized compendia, clinical guidelines, and literature • Conduct computer-based reviews of drug coverage appeals • Participate in peer-to-peer discussions with prescribers • Participate in hearings involving an Administrative Law Judge • Support CMS audits • Collaborate with clinicians, support staff, and inter- and intra-departmental resources • Participate in cross-functional team activities • Learn Medicare Part D and Medicare Advantage requirements and operationalize them in daily work • Support optimal value-based care in accordance with Medicare and Humana policy

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience post completion of doctorate • Preferably some experience related to a Medicare type population (disabled or >65 years of age) • Current and ongoing Board Certification, with preference for Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation • Current and unrestricted physician license in at least one jurisdiction • Willingness to obtain an additional license if required • 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 focused 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 Medicare Advantage, managed Medicaid, or Commercial health insurance • 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 • Curiosity to learn, flexibility to adapt, courage to innovate • Experience functioning as a team member, providing support to reach a common goal • Minimum 25 Mbps download and 10 Mbps upload internet speed for home or hybrid home/office work • Ability to work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Telephone equipment appropriate to business requirements • Bi-weekly internet expense payment for employees who live and work from home in California, Illinois, Montana, or South Dakota