Medical Director – Medicare Pharmacy
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Job Description
Medical Director reviewing Medicare Part D and B drug appeals for Humana, a U.S. healthcare and insurance company. Applying clinical expertise, Medicare rules, and medical-necessity criteria.
Responsibilities:
- 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
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