Unknown Company is hiring a Medical Director – Medicare Pharmacy Appeals, Part Time, Seasonal

Humana is looking for a Medical Director to bring broad clinical expertise to reviewing Medicare drug appeals (Part D & B). This is a non-benefited, part-time, seasonal role compensated hourly, where you will analyze moderately complex to complex cases considering Medicare rules, Humana policies, and medical necessity. Join a caring community dedicated to putting health first.

What You'll Do

• Review Medicare drug appeals (Part D & B) using clinical expertise, CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature.
• Conduct computer-based review of moderately complex to complex appeals for drug coverage.
• Engage in Peer to Peer discussions with prescribers.
• Participate in hearings involving an Administrative Law Judge.
• Provide support for CMS audits and cross-functional team activities.
• Collaborate with clinicians and support staff to provide Humana members with optimal value-based care in accordance with Medicare and Humana policy.

What We're Looking For

• MD or DO degree.
• Current and ongoing Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation.
• A current and unrestricted license in at least one jurisdiction and willingness to obtain additional license, if required.
• No current sanction from Federal or State Governmental organizations, and ability 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.

Nice to Have

• 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.
• 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).
• Experience with national guidelines, such as MCG, InterQual, NCCN, Micromedex, Lexicomp, 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.

Benefits & Compensation

• Compensation range: $223,800 - $313,100 per year.
• Paid time off.
• 401(k) retirement savings plan.
• Employee assistance program.
• Business travel and accident insurance.

Work Mode

This is a fully remote position.

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.