Medicare Appeals Medical Director (Remote)

Humana Inc; Atlanta (GA); À distance; USD 224 000 - 313 000; Plein temps

Résumé du poste

Humana Inc. seeks a Medical Director to review Medicare drug appeals (Part D & B) with broad clinical expertise. The role involves case-by-case analysis, policy alignment, and collaboration with clinicians to ensure value-based care within Medicare rules.

This remote position requires 40 hours weekly, with a competitive pay range and bonus eligibility. You will work with cross-functional teams, support CMS audits, and participate in hearings as needed.

Qualifications

• MD or DO degree required.
• 5+ years of direct clinical patient care experience post doctorate.
• Board Certification in Internal Medicine, Family Medicine, Emergency Medicine or PM&R preferred.
• Current and unrestricted physician license in at least one jurisdiction.
• No sanctions and able to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Analytic and interpretation skills in quality/utilization contexts.

Responsabilités

• Review Medicare drug appeals (Part D & B) using Medicare rules and Humana policy.
• Perform computer-based reviews of moderately to complex drug coverage appeals.
• Engage in Peer to Peer discussions with prescribers and participate in hearings with an Administrative Law Judge as needed.
• Support CMS audits and cross-functional team activities to ensure value-based care.
• Ensure regulatory compliance and leverage CMS policies, NCCN, and Humana procedures in daily work.

Connaissances

Clinical expertise

Decision making

Communication skills

Analytic skills

Formation

MD or DO degree

Description du poste

Humana Inc. seeks a Medical Director to review Medicare drug appeals (Part D & B) with broad clinical expertise. The role involves case-by-case analysis, policy alignment, and collaboration with clinicians to ensure value-based care within Medicare rules.

This remote position requires 40 hours weekly, with a competitive pay range and bonus eligibility. You will work with cross-functional teams, support CMS audits, and participate in hearings as needed.