Medical Director – Pharmacy Appeals

Jobtailor; Deutschland; Hybrid; EUR 120.000 - 180.000; Vollzeit

Zusammenfassung

Jobtailor seeks a licensed physician (MD/DO) with board certification to review Medicare drug appeals, analyze complex cases using Medicare rules, Humana policies, and clinical guidelines, and participate in peer discussions with prescribers. You will collaborate with clinicians, support CMS audits, and contribute to quality management programs.

Requires current unrestricted license, willingness to obtain additional license if needed, strong verbal and written communication, and ability to work

Qualifikationen

• MD or DO degree with board certification.
• 5+ years of direct clinical patient care experience post doctorate.
• Current and unrestricted physician license in at least one jurisdiction.
• Strong analytical, interpretative, and communication skills.
• Experience with quality/utilization management and Medicare guidelines.

Aufgaben

• Review Medicare drug appeals for Part D and Part B coverage.
• Analyze complex cases using Medicare rules, CMS policies, and clinical guidelines.
• Conduct computer-based reviews of drug coverage appeals.
• Participate in peer-to-peer discussions with prescribers.
• Support CMS audits and participate in hearings.
• Collaborate with clinicians and cross-functional teams.

Kenntnisse

Medicare Drug Appeals Review

Clinical Guidelines Analysis

Utilization Management

Analytic And Interpretation Skills

Peer-To-Peer Discussions

CMS Audits

Cross-Functional Team Collaboration

National Guidelines (MCG, InterQual, 3

Public Health Analytics

Business Metrics Utilization

Ausbildung

MD or DO degree

Board Certification

Jobbeschreibung

• 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

Core Competencies

Demonstrates expertise in Medicare drug appeals, clinical guidelines, and utilization management, with a strong foundation in patient care and collaboration across multidisciplinary teams. Holds a current physician license and board certification, ensuring compliance with healthcare regulations and standards.

Highest-signal resume keywords

• MD Or DO Degree
• 5+ Years Clinical Patient Care Experience
• Board Certification In Internal Medicine, Family Medicine, Emergency Medicine, Or Physical Medicine And Rehabilitation
• Utilization Management Experience In Medicare Advantage
• Knowledge Of Managed Care Industry

Hard Skills

• Medicare Drug Appeals Review
• Clinical Guidelines Analysis
• Utilization Management
• Analytic And Interpretation Skills
• Peer-To-Peer Discussions
• Support CMS Audits
• Cross-Functional Team Collaboration
• Knowledge Of National Guidelines (MCG, InterQual, NCCN)
• Public Health And Population Health Analytics
• Business Metrics Utilization

Soft Skills

• Excellent Verbal And Written Communication Skills
• Curiosity To Learn
• Flexibility To Adapt
• Courage To InnovateTeam Collaboration

Certifications & Qualifications

• Current And Unrestricted Physician License
• Board Certification

Industry Keywords

• Medicare Part D
• Medicare Advantage
• Clinical Group Practice Management
• Integrated Delivery Systems
• Health Insurance
• Quality Management
• Utilization Management
• CMS Policies
• Medical Necessity Criteria
• PHI/HIPAA Compliance