Medical Director – Pharmacy Appeals

🔥 3 minutes 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 under Part D and Part B • Analyze moderately complex to complex cases using Medicare rules, Humana policies, medical necessity criteria, CMS policies, coverage determinations, recognized compendia, clinical literature, and departmental resources • Conduct peer-to-peer discussions with prescribers • Participate in hearings involving an Administrative Law Judge • Support CMS audits • Participate in cross-functional team activities • 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 all work within regulatory compliance requirements • Travel occasionally to Humana offices for training or meetings

🎯 Requirements

• MD or DO degree • 5+ years of direct clinical patient care experience post completion of doctorate • 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 additional license, if required • No current sanction from Federal or State Governmental organizations • Ability 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 • 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 • Minimum home internet speed of 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical benefits • Dental benefits • Vision benefits • 401(k) retirement savings plan • Paid time off • Company holidays • Personal holidays • Paid parental leave • Paid caregiver leave • Short-term disability • Long-term disability • Life insurance • Telephone equipment appropriate to business requirements 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