Medical Director – Pharmacy Appeals
Employment Information
Job Description
Medical Director managing Medicare drug appeals for Humana. Collaborating with clinicians to provide value-based care and support for audits and cross-functional activities.
Responsibilities:
- The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B)
- Collaborate with clinicians and support staff to provide Humana members with optimal value based care in accordance with Medicare and Humana policy
- Participate in hearings involving an Administrative Law Judge
- Support for CMS audits
- Cross-functional team activities
- Computer based review of moderately complex to complex appeals for coverage for drugs using resources outlined above
Requirements:
- MD or DO degree
- 5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience related to a Medicare type population (disabled or >65 years of age)
- A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
- No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
- Excellent verbal and written communication skills
- Evidence of analytic and interpretation skills, with 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 (preferred)
- Utilization management experience in a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial health insurance (preferred)
- Current and ongoing Board Certification in Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation (preferred)
- Experience with national guidelines, such as MCG, InterQual, NCCN, Micromedex, Lexicomp, Elsevier’s Clinical Pharmacology (preferred)
- Exposure to Public Health, Population Health, analytics, and use of business metrics (preferred)
- Curiosity to learn, flexibility to adapt, courage to innovate (preferred)
- Experience functioning as a Team member, providing support to reach a common goal (preferred)
Benefits:
- medical, dental and vision benefits
- 401(k) retirement savings plan
- time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
- short-term and long-term disability
- life insurance
- many other opportunities
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