Medicare Appeals Medical Director—Value‑Based Care (Remote)

Humana Inc; Trenton (NJ); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. is seeking a Medical Director to review Medicare drug appeals (Part D & B) and to support value-based care in accordance with Medicare rules and Humana policy.

The role involves computer-based review of complex drug coverage appeals, collaboration with clinicians, and participation in hearings and CMS audits as needed. The successful candidate will have an MD or DO, Board Certification, and an active license in at least one state.

Qualifications

• MD or DO degree required.
• Board Certification with preference for Internal Medicine, Family Medicine, Emergency Medicine or PM&R.
• Current and unrestricted physician license in at least one jurisdiction; willing to obtain 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; experience in quality/utilization management.

Responsibilities

• Review Medicare drug appeals (Part D & B) using Medicare rules and Humana policies.
• Perform computer-based review of moderately complex to complex drug coverage appeals.
• Collaborate with clinicians and staff to ensure value-based care.
• Participate in peer discussions with prescribers and in hearings with Administrative Law Judge where needed.
• Support CMS audits and cross-functional team activities in compliance with Medicare and Humana policy.

Education

MD or DO degree

Board Certification (Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation)

Job description

Humana Inc. is seeking a Medical Director to review Medicare drug appeals (Part D & B) and to support value-based care in accordance with Medicare rules and Humana policy.

The role involves computer-based review of complex drug coverage appeals, collaboration with clinicians, and participation in hearings and CMS audits as needed. The successful candidate will have an MD or DO, Board Certification, and an active license in at least one state.